Surgical & Regenerative Periodontal Therapy MCQ

Periodontal surgery enters when nonsurgical therapy leaves residual disease, or when defect morphology, esthetics, or restorative needs demand it. It is not one operation but several, each matched to a problem: access flaps to clean what scaling could not reach, resective surgery to reduce pockets by reshaping bone, regenerative procedures to rebuild lost attachment in the right defects, mucogingival (plastic) surgery to cover recession and add keratinized tissue, and crown lengthening to reestablish restorative space. The recurring principle is that the right operation depends on the defect, and that none of it holds without controlled plaque. Implant placement itself belongs to prosthodontics and oral surgery; periodontics owns the soft-tissue and regenerative surgery around teeth.

Access Flap Surgery

• Open-flap debridement reflects a flap to gain direct access to root surfaces and bony defects that scaling and root planing could not reach in deep pockets.
• It is the most conservative surgical option: the flap is replaced (repositioned) after the roots are cleaned and the defect is debrided, aiming for healing with reduced pocket depth.
• Access surgery is chosen for residual deep, bleeding pockets after nonsurgical therapy when the goal is debridement rather than pocket elimination by bone removal.
• Like all periodontal surgery, it depends on adequate plaque control before and after, or the result will not hold.

Resective Surgery

• Resective osseous surgery reduces pockets by reshaping the alveolar bone to a positive architecture and apically positioning the flap, eliminating the pocket at the cost of sacrificing some bony support.
• Gingivectomy is the surgical excision of gingiva, used for gingival enlargement or suprabony pseudopockets where there is adequate attached gingiva and no need to access bone.
• An apically positioned flap reduces the pocket while preserving the band of keratinized tissue by moving it apically rather than excising it.
• Resective approaches trade some support and can expose more root, so they are chosen when pocket elimination is the priority and the defect is not suited to regeneration.

Regenerative Surgery

• Regeneration aims to rebuild the lost attachment apparatus (new cementum, periodontal ligament, and bone), not merely to repair with a long junctional epithelium.
• Guided tissue regeneration (GTR) places a barrier membrane to exclude the fast-growing gingival epithelium and connective tissue, giving the slower periodontal ligament and bone cells time to repopulate the defect.
• Bone grafts are classified as autograft (the patient's own bone, the osteogenic gold standard), allograft (same species, such as demineralized freeze-dried bone), xenograft (another species), and alloplast (synthetic); enamel matrix derivative (EMD) is a biologic that promotes regeneration.
• Regeneration works best in contained defects with remaining bony walls, classically three-wall vertical (infrabony) defects and Class II furcations; horizontal bone loss and through-and-through (Class III) furcations are poor candidates.

Mucogingival (Plastic) Surgery

• Mucogingival surgery addresses soft-tissue problems: covering gingival recession and increasing the zone of keratinized (attached) tissue.
• A free gingival graft (typically from the palate) is used mainly to increase the width of keratinized tissue.
• A subepithelial connective tissue graft is the workhorse for root coverage of recession defects and is considered a gold standard for predictable coverage and esthetics.
• A coronally advanced flap, often combined with a connective tissue graft, moves keratinized tissue coronally to cover an exposed root.

Crown Lengthening and Furcation Management

• Crown lengthening exposes more sound tooth structure and reestablishes the supracrestal attachment so a restoration can be placed without violating it; it usually requires removing bone (and soft tissue) to relocate the attachment apically.
• Crown lengthening is functional (to gain restorative space for a subgingival margin or a short clinical crown) or esthetic (to correct a 'gummy' smile by exposing more crown).
• Furcation management depends on the grade: Class I may be treated by scaling and odontoplasty, Class II is a candidate for regeneration, and Class III (through-and-through) often requires tunneling, root resection or hemisection, or extraction.
• Root resection or hemisection removes one root (or splits a multirooted tooth) to eliminate an untreatable furcation or a root with a problem, retaining the salvageable portion.