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PRE-PROSTHETIC PERIODONTAL SURGERIES

Comprehensive Theory Examination Notes for Postgraduate Periodontology

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SECTION 1: DEFINITION AND OVERVIEW

"The preparation of the periodontium for restorative dentistry can be divided into two phases: (1) control of periodontal inflammation with nonsurgical and surgical approaches and (2) preprosthetic periodontal surgery."

• Carranza's Clinical Periodontology, 10th Edition, Chapter 71

"Periodontal health is the sine qua non of successful, patient centric, interdisciplinary, comprehensive dentistry."

• Newman and Carranza's Clinical Periodontology and Implantology, 14th Edition, Chapter 66

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SECTION 2: RATIONALE FOR PRE-PROSTHETIC PERIODONTAL SURGERY

1. Periodontal treatment establishes stable gingival margins before tooth preparation. Noninflamed, healthy tissues are less likely to change (e.g., shrink or recede) as a result of subgingival restorative treatment or postrestoration periodontal care. Tissues that do not bleed during restorative manipulation allow for a more predictable restorative and esthetic result.
2. Certain periodontal procedures provide adequate tooth length for retention, access for tooth preparation, impression making, tooth preparation, and finishing of restorative margins. Failure to complete these procedures before restorative care can add to the complexity of treatment and introduce unnecessary risk of failure.
3. Periodontal therapy should antecede restorative care because the resolution of inflammation may result in the repositioning of teeth or in soft tissue and mucosal changes. Failure to anticipate these changes may interfere with prosthetic designs planned or constructed before periodontal treatment.
4. Traumatic forces placed on teeth with ongoing periodontitis may increase tooth mobility, discomfort, and possibly the rate of attachment loss. Restorations constructed on teeth free of periodontal inflammation, synchronous with a functionally appropriate occlusion, are more compatible with long-term periodontal stability and comfort.
5. Quality, quantity, and topography of the periodontium may play important roles as structural defense factors in maintaining periodontal health. Orthodontic tooth movement and restorations completed without the benefit of periodontal treatment designed for this purpose may be subject to negative changes that complicate construction and future maintenance.
6. Successful esthetic and implant procedures may be difficult or impossible without the specialized periodontal procedures developed for this purpose.

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SECTION 3: SEQUENCE OF TREATMENT IN PREPARING THE PERIODONTIUM FOR RESTORATIVE DENTISTRY

FLOWCHART: Sequence of Treatment (Box 71-1)

┌─────────────────────────────────────────────┐
│      CONTROL OF ACTIVE DISEASE               │
│  ↓ Emergency treatment                       │
│  ↓ Extraction of hopeless teeth              │
│  ↓ Oral hygiene instructions                 │
│  ↓ Scaling and root planing                  │
│  ↓ Reevaluation                              │
│  ↓ Periodontal surgery                       │
│  ↓ Adjunctive orthodontic therapy            │
└────────────────┬────────────────────────────┘
                 ↓
┌─────────────────────────────────────────────┐
│         PREPROSTHETIC SURGERY                │
│  1. Management of mucogingival problems      │
│  2. Preservation of ridge morphology         │
│     after tooth extraction                   │
│  3. Crown-lengthening procedures             │
│  4. Alveolar ridge reconstruction            │
└─────────────────────────────────────────────┘

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SECTION 4: CLASSIFICATION OF PRE-PROSTHETIC PERIODONTAL SURGERIES

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SECTION 5: ENUMERATION AND DESCRIPTION OF PRE-PROSTHETIC PERIODONTAL SURGERIES

I. MANAGEMENT OF MUCOGINGIVAL PROBLEMS

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A. WIDENING OF ATTACHED GINGIVA (Mucogingival / Periodontal Plastic Surgery)

• Teeth with subgingival restorations and narrow zones of keratinized gingiva have higher gingival inflammation scores than teeth with similar restorations and wide zones of attached gingiva.
• Wider zone of attached gingiva is needed around teeth that serve as abutments for fixed or removable partial dentures, as well as in ridge areas in relation to dentures.
• "In such cases, techniques for widening the attached gingiva are considered preprosthetic periodontal surgical procedures." (Carranza's 10th Ed., Ch. 69)

1. Enhances plaque removal around the gingival margin
2. Improves esthetics
3. Reduces inflammation around restored teeth
4. (14th Ed. adds): Allows the gingival margin to bind better around teeth and implants with attached gingiva

• Donor tissue (epithelium + connective tissue) harvested from the palate
• Placed on a prepared recipient bed (periosteum-covered or denuded bone)
• After 24 weeks: grafts placed on denuded bone shrink 25%, grafts on periosteum shrink 50%. Greatest shrinkage occurs within first 6 weeks.
• Revascularization starts by 2nd or 3rd day; central surface completes vascularization by 10th day.
• Functional integration occurs by the 17th day.
• Microscopically, healing of intermediate thickness graft (0.75 mm) is complete by 10.5 weeks; thicker grafts (1.75 mm) may require 16 weeks or longer.
• Heterotopically placed grafts maintain their keratinized structure even after epithelium becomes necrotic - indicating genetic predetermination of the specific character of oral mucosa depending on connective tissue stimuli.

• Deeper portion of palatal donor tissue consists only of connective tissue
• Can be used as free graft on recipient site
• Advantage: minimal donor site wound - two grafts obtained from one site

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B. PROBLEMS ASSOCIATED WITH SHALLOW VESTIBULE — VESTIBULOPLASTY

• Gingival recession displaces the gingival margin apically, reducing vestibular depth.
• With minimal vestibular depth, proper hygiene procedures are jeopardized (Bass technique placement is impossible).
• "Adequate vestibular depth is also necessary for the proper placement of removable prostheses." (Newman and Carranza's 14th Edition, Chapter 65)

• Minimal keratinized attached gingiva with no vestibular depth
• To aid in proper placement of removable prostheses

FLOWCHART: Clark's Vestibuloplasty

Step 1: Horizontal incision from canine to canine
        between attached gingiva and alveolar mucosa
                    ↓
Step 2: Supraperiosteal dissection performed.
        Fibrous tissue attached to periosteum is
        scraped away thoroughly
                    ↓
Step 3: The mucosa is sutured at the depth of the vestibule

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C. FRENECTOMY AND FRENOTOMY

• Frenectomy: Complete removal of the frenum, including its attachment to the bone. Indicated for correction of abnormal diastema.
• Frenotomy: Incision and relocation of the frenum to create a zone of attached gingiva between the gingival margin and the frenum (suffices for periodontal problems).

1. The accumulation of irritants
2. The deflection of the wall of the periodontal pocket, which may aggravate its severity
3. Interference with post-treatment healing
4. Pocket formation
5. Injury while brushing

FLOWCHART: Frenectomy Technique

Step 1: Anesthetize the area
        ↓
Step 2: Engage the frenum with a hemostat
        ↓
Step 3: Removal of the triangular resected portion of the frenum
        ↓
Step 4: The wound is closed with interrupted sutures

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D. ROOT COVERAGE PROCEDURES

• Protection of the denuded root from structural damage
• Confluence of gingival margin levels to aid in plaque control efforts
• Patient comfort
• Preprosthetic purpose: widening the zone of attached gingiva around future abutment teeth

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II. PRESERVATION OF RIDGE MORPHOLOGY AFTER TOOTH EXTRACTION

• "Alveolar ridge resorption is a natural consequence of tooth loss."
• Spontaneous, unaided healing results in:
  • Significant horizontal (29%–63%) reduction in ridge dimension (Newman-Carranza 14th Ed.)
  • Significant vertical (11%–22%) reduction in ridge dimension (Newman-Carranza 14th Ed.)
• "These changes are rapid in the first 3 to 6 months and occur gradually thereafter."
• The buccal aspect of bone resorbs at a faster rate, resulting in a lingual-palatal shift of the bone crest, with more pronounced resorption in the mandible than in the maxilla.
• "At 1 year, up to 50% loss of horizontal dimension can be anticipated." (Newman-Carranza 14th Ed.)

• Anticipation of future dental implant placement
• Preservation of tissues beneath pontics of fixed partial dentures
• Situations where unaided healing would result in an unesthetic deformity

• Socket is atraumatically debrided while maintaining surrounding anatomic integrity.
• Socket grafted (e.g., combination of deproteinized bovine bone and calcium sulfate)
• Provisional fixed partial denture placed with an ovate pontic extending 2 mm into the socket and supporting surrounding tissues

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III. CROWN-LENGTHENING PROCEDURES

• Provide retention form to allow for proper tooth preparation
• Allow for impression procedures and placement of restorative margins
• Adjust gingival levels for esthetics

"The biologic width is defined as the physiologic dimension of the junctional epithelium and connective tissue attachment."

The biologic width has been estimated to be about 2 mm (±30%) (Gargiulo et al.).

The healthy gingival sulcus has shown an average depth of 0.69 mm.

"It has been theorized that infringement on the biologic width by the placement of a restoration within its zone may result in gingival inflammation, pocket formation, and alveolar bone loss."

"It is recommended that there be at least 3.0 mm between the gingival margin and bone crest."

(Carranza's 10th Ed., Ch. 71)

"The junctional epithelium (JE) and connective tissue attachment (CTA) make up the supracrestal tissue attachment (SCTA) (formerly the biologic width)."

(Newman and Carranza's 14th Edition, Chapter 66)

• Same average width of 2 mm confirmed
• Range: as narrow as 0.75 mm to as tall as 4.3 mm in different individuals
• This dictates that specific biologic width assessment should be performed for each patient

• "Sounding to bone" (probing to bone level through anesthetized attachment tissues)
• If distance from bone to restoration margin is less than 2 mm at one or more locations, biologic width violation is confirmed
• Assessment completed circumferentially around the tooth

• Esthetics
• Clinical crown-root ratio
• Root proximity
• Root morphology
• Furcation involvement
• Individual tooth position
• Collective tooth position
• Ability to restore the teeth

• Surgery is the more rapid of the two treatment options
• Preferred if the resulting crown lengthening will create a more pleasing tooth length
• The bone should be moved away from the margin by the measured distance of the ideal biologic width, with an additional 0.5 mm of bone removed as a safety zone
• If biologic width violation is on the interproximal side, or violation is across the facial surface with correct gingival tissue level, orthodontic extrusion is indicated (to avoid papillary recession and creation of unesthetic triangle of space)

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IV. ALVEOLAR RIDGE RECONSTRUCTION (RIDGE AUGMENTATION)

• Esthetic pontic construction
• Implant site development
• Cases where unaided healing results in esthetic deformity

FLOWCHART: Selection of Ridge Augmentation Procedure

          Ridge Defect Present
                  ↓
    ┌─────────────────────────────┐
    │      Assess defect size      │
    └─────┬───────────────────────┘
          ↓                   ↓
   Small Defect          Larger Defect /
   (esthetic pontic)     Implant Site
          ↓                   ↓
Soft Tissue Ridge      Hard Tissue
Augmentation           Augmentation
(CTG, Onlay graft)    (GBR, Block graft)

A. SOFT TISSUE RIDGE AUGMENTATION

• Receptor site formed with a diamond bur or by electrosurgery
• In highly esthetic areas (maxillary anterior): receptor area 1.0 to 1.5 mm below the tissue on the facial aspect - creates appearance of free gingival margin
• "If the tissue is removed to less than 2 mm in thickness, significant rebound in ridge height may occur."
• If necessary to reduce tissue height to less than 2 mm above bone, some bone will need to be removed

B. HARD TISSUE RIDGE AUGMENTATION

• "Predictability for bone formation is better in horizontal ridge augmentation procedures than in vertical ridge augmentation." (Carranza's 10th Ed., Ch. referenced sections)
• "In cases of advanced bone resorption, ridge augmentation predictability is better for horizontal than vertical augmentation."

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V. ANTERIOR ESTHETIC SURGERY (PERIODONTAL-PROSTHETIC CORRECTIONS)

1. Gingivectomy
2. Apically positioned flaps with osseous recontouring
3. Orthodontic therapy - to position gingival tissue level apically or coronally by intruding or extruding teeth

• Constructed directly on stone cast
• Used when surgery involves many or all anterior teeth and results in moving gingiva several millimeters
• Determines desired incisal edge position and desired gingival level
• Composite or acrylic resin veneer constructed on cast extending gingivally to desired tissue position
• Can be extended incisally to desired incisal edge position
• "When the patient approves the gingival levels established with the guide, the desired gingival correction can be completed using the veneer guide as a surgical template."

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VI. INTERDENTAL PAPILLA RECONSTRUCTION

1. Beagle (1992): Pedicle graft procedure utilizing a split-thickness flap dissected from the palatal aspect of the interdental area; flap elevated labially, folded, and sutured to create new facial papilla.
2. Han and Takei (1996): Semilunar coronally repositioned flap based on the use of a free connective tissue graft.
3. Many other techniques proposed, some utilizing microsurgery.

• "None of them have exhibited any predictable results." (S. Reddy, Ch. 43)

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SECTION 6: COMPARISON TABLE - DIFFERENT VIEWPOINTS FROM REFERENCES

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SECTION 7: IMPORTANT TERMINOLOGY AND RECENT CHANGES

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SECTION 8: SUMMARY TABLE — ALL PRE-PROSTHETIC PERIODONTAL SURGERIES

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SECTION 9: EXAMINER-CRITICAL KEYWORDS TO HIGHLIGHT

• Preprosthetic periodontal surgery (vs. pre-prosthetic surgery - note usage in both formats in texts)
• Supracrestal Tissue Attachment (SCTA) - formerly Biologic Width (Newman-Carranza 14th Ed.)
• Biologic width = ~2 mm (±30%); range 0.75 mm to 4.3 mm (Vacek et al. 1994)
• 3 mm from gingival margin to bone crest = recommended minimum
• 4 mm from apical caries/fracture to bone crest = requirement for caries/fracture cases
• Sounding to bone = method to individually assess biologic/attachment width
• 0.5 mm safety zone = additional bone removal during crown lengthening correction
• Periodontal plastic surgery = modern term for mucogingival surgery (1996 World Workshop)
• Ovate pontic = ideal pontic form; receptor site 1.0-1.5 mm below tissue in esthetic zone
• Horizontal ridge resorption 29%–63%; vertical 11%–22% (Newman-Carranza 14th Ed.)
• Up to 50% horizontal dimension loss at 1 year (Newman-Carranza 14th Ed.)
• Ridge preservation limits but does not prevent resorption (Newman-Carranza 14th Ed.)
• Revascularization of FGG: 2nd-3rd day; complete by 10th day centrally; functional integration 17th day
• FGG shrinkage: 25% on bone, 50% on periosteum at 24 weeks; greatest in first 6 weeks
• Frenectomy (complete removal including bone) vs. Frenotomy (incision + relocation)
• Clark's vestibuloplasty = technique for vestibular deepening
• Sine qua non = periodontal health as prerequisite for restorative dentistry (Newman-Carranza 14th Ed.)
• At least 2 months healing after soft tissue grafting before initiating restorative dentistry (Newman-Carranza 14th Ed.)

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SECTION 10: SCOPE OF PERIODONTAL PLASTIC SURGERY (1996 WORLD WORKSHOP)

1. Periodontal-prosthetic corrections
2. Crown lengthening
3. Ridge augmentation
4. Esthetic surgical corrections
5. Coverage of the denuded root surface
6. Reconstruction of papillae
7. Esthetic surgical correction around implants
8. Surgical exposure of unerupted teeth for orthodontics

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KEY SOURCE DOCUMENTS USED

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• Carranza's Clinical Periodontology, 10th Edition - Primary source for Box 71-1 classification, crown lengthening parameters, biologic width, ridge augmentation, pontic design, FGG healing, mucogingival/periodontal plastic surgery objectives and techniques
• Newman and Carranza's Clinical Periodontology and Implantology, 14th Edition - Updated SCTA terminology (formerly biologic width), quantified ridge resorption data (29-63% horizontal; 11-22% vertical), Chapter 66 rationale and sequence
• Essentials of Clinical Periodontology and Periodontics (S. Reddy) - Clark's vestibuloplasty steps, frenectomy/frenotomy distinction and types, crown lengthening objectives and technique selection criteria, papilla reconstruction techniques

1. The SCTA (Supracrestal Tissue Attachment) is the current terminology replacing "biologic width" - a frequently tested recent change
2. The four-category classification from Box 71-1 (Carranza's 10th Ed.) is the standard enumeration answer expected
3. Biologic width parameters (2 mm average, 3 mm minimum from margin to bone, 4 mm for caries/fracture cases, 0.5 mm safety zone) are commonly examined numeric values
4. The distinction between frenectomy vs. frenotomy and the four types of frenal attachments are short-answer favorites
5. Clark's vestibuloplasty steps and FGG healing stages with specific time points are frequently tested

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LANDMARK RESEARCH ARTICLES: PRE-PROSTHETIC PERIODONTAL SURGERIES

MDS Periodontology Examination-Relevant Literature Review

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CATEGORY 1: FOUNDATIONAL / CLASSIC PAPERS (Pre-PubMed Era — Must-Know for Examiners)

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Paper 1

• Established the foundational measurements of the dentogingival junction: sulcus depth mean 0.69 mm, junctional epithelium 0.97 mm, connective tissue attachment 1.07 mm
• Total biologic width = ~2 mm (JE + CTA)
• Provided the biological rationale for all crown-lengthening procedures and the concept of minimum 3 mm from restorative margin to alveolar bone crest

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Paper 2

• Introduced orthodontic forced eruption as a pre-prosthetic procedure
• Part I: demonstrated coronal movement of bone and soft tissue attachment with tooth extrusion, effectively eliminating infrabony defects
• Part II: extended to non-restorable teeth — extrusion moves the fracture/caries margin coronally so that crown lengthening or direct restoration becomes possible
• Established the concept that orthodontic tooth movement is an alternative/adjunct to surgical crown lengthening for biologic width management

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Paper 3

• Introduced the term "mucogingival surgery" to describe surgical procedures for correction of relationships between the gingiva and the oral mucous membrane
• Defined three specific problem areas: attached gingiva, shallow vestibules, and a frenum interfering with the marginal gingiva
• Laid the conceptual framework later renamed "periodontal plastic surgery" at the 1996 World Workshop

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Paper 4

• Proposed the term "periodontal plastic surgery" as a replacement for mucogingival surgery
• Broadened the scope to include: crown lengthening, ridge augmentation, root coverage, papilla reconstruction, esthetic surgical corrections around implants
• This terminology was officially adopted at the 1996 World Workshop in Clinical Periodontics

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Paper 5

• Introduced the Seibert classification of ridge defects:
  • Class I: Buccolingual loss of tissue width, normal ridge height
  • Class II: Apicocoronal loss of tissue height, normal ridge width
  • Class III: Combination defect — loss of both height and width
• Described full-thickness onlay grafts for ridge reconstruction
• Established the relationship between ridge morphology and pontic design

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CATEGORY 2: CROWN LENGTHENING — KEY CLINICAL STUDIES

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Paper 6

• Immediately post-surgery: mean clinical crown length gained = 3.7 mm interproximally, 4.1 mm buccally/lingually
• Over 12-month healing: coronal rebound of the gingival margin = 3.2 mm interproximally, 2.9 mm buccally/lingually
• Net available tooth structure at 12 months: only 0.5 mm interproximally and 1.2 mm buccally/lingually
• Coronal rebound was more pronounced in "thick" tissue biotype
• Rebound was influenced by individual healing variation (not age or gender)

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Paper 7

• Synthesized evidence on crown-lengthening rationale, surgical principles, contraindications, and wound healing
• Key clinical finding synthesized: average of 3 mm of supragingival soft tissue will rebound coronal to the alveolar crest post-surgery, requiring minimum 3 months to complete vertical growth
• Clinical implication: Final prosthetic treatment should wait at least 3 months; up to 6 months for esthetically important areas
• Addressed: ferrule length, biologic width establishment, indications for gingivectomy vs. apically positioned flap with osseous resection

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Paper 8

• Addressed the four critical questions in esthetic crown lengthening: ideal flap design, amount of supporting bone to remove, position of flap margin relative to alveolar bone at surgical closure, and timing/position of provisional restoration during healing
• Described the concept of "crown lengthening in the esthetic zone" as distinct from posterior functional crown lengthening
• Discussed altered passive eruption as a specific indication
• Emphasized integration of provisional restoration position in managing gingival healing outcomes

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CATEGORY 3: ALVEOLAR RIDGE PRESERVATION — KEY EVIDENCE

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Paper 9

• First high-quality meta-analysis quantifying the benefit of ridge preservation after extraction
• Key findings: ARP effective vs. extraction alone with benefit of:
  • 1.89 mm horizontally (buccolingual)
  • 2.07 mm vertically (midbuccal)
  • 1.18 mm vertically (midlingual)
• Subgroup: flap elevation + membrane + xenograft/allograft associated with superior outcomes
• Confirmed ARP is effective in limiting physiologic ridge reduction

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Paper 10

• Updated meta-analysis; 22 RCTs included; 9 different ARP treatment modalities identified
• Pooled result for ARP via socket grafting vs. extraction alone:
  • Horizontal: 1.99 mm (95% CI 1.54–2.44)
  • Vertical midbuccal: 1.72 mm (95% CI 0.96–2.48)
  • Vertical midlingual: 1.16 mm (95% CI 0.81–1.52)
• Sites with buccal bone thickness >1.0 mm showed markedly superior outcomes (3.2 mm difference vs. 1.29 mm in thin-walled sockets)
• Xenogenic or allogenic materials + absorbable collagen membrane/sponge associated with most favourable outcomes

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Paper 11

• 16 RCTs, 524 extraction sites, 426 adult participants
• Quantified: xenograft ARP vs. extraction alone shows significant reduction in ridge width loss (MD -1.18 mm, 95% CI -1.82 to -0.54) and height loss (MD -1.35 mm, 95% CI -2.00 to -0.70)
• However: "very low certainty evidence" — did not find significant difference in need for additional augmentation before implant placement
• Key conclusion: ARP reduces dimensional change but does not eliminate the need for augmentation in all cases

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Paper 12

• Primary outcome: horizontal bone preservation benefit = 1.86 mm (95% CI 1.44–2.28)
• Identified five clinical factors significantly affecting outcomes:
  1. Type of wound closure
  2. Type of grafting material
  3. Use of barrier membranes
  4. Use of growth factors
  5. Socket morphology (intact vs. compromised walls)
• Provided evidence hierarchy for material and technique selection in ARP

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CATEGORY 4: MUCOGINGIVAL / FREE GINGIVAL GRAFT — LANDMARK PAPERS

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Paper 13

• Introduced the free gingival graft (FGG) technique in its modern form
• Described the principles of plasmatic circulation, revascularization, and graft take
• Established three phases of FGG healing: initial plasmatic circulation → revascularization (Day 2–3) → organisational phase
• Demonstrated FGG as a reliable method for widening attached gingiva

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Paper 14

• Introduced the subepithelial connective tissue graft (SCTG) — the "gold standard" of root coverage and attached gingiva augmentation
• Described harvesting of a connective tissue graft from the palate placed beneath a partial-thickness envelope flap
• Advantages over FGG: superior esthetics (color match), protection of donor site, ability to cover wider and deeper recessions
• Applicable as a preprosthetic procedure around future abutment teeth and implants

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CATEGORY 5: RIDGE AUGMENTATION FOR PONTIC/IMPLANT — ADDITIONAL LANDMARKS

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Paper 15

• Described staged (two-stage) ridge augmentation before implant placement
• Demonstrated that adequate ridge volume should be established before implant surgery rather than simultaneously in severely deficient ridges
• Supported the concept that predictability of bone formation is better in horizontal than vertical ridge augmentation
• Contributed to the framework for pre-prosthetic hard tissue site development

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Paper 16

• Confirmed the mean biologic width of ~2 mm but, critically, reported a range of 0.75 mm to 4.3 mm between individuals
• Demonstrated that biologic width is patient-specific and not uniform
• Established the need for individual "sounding to bone" assessment for each patient before restorative treatment
• Showed that some patients can have biologic width violations even when margins are >2 mm above alveolar bone

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QUICK REFERENCE SUMMARY TABLE

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EXAMINER'S EXPECTED CITATION PAIRS