Periodontal Pockets

Periodontal pockets are defined as a pathologically

deepened gingival sulcus; it is one of the important
features of periodontal disease.

Classification
Deepening of the gingival sulcus may occur by coronal movement of
the gingival margin or apical displacement of the gingival attachment
or combination of the two processes. Pockets are classified into:
 Classification of pockets
↓
↓¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯↓
Gingival pocket Periodontal pocket
[Relative or False] [Absolute or True]
Pseudo |
|¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯|
Suprabony Infrabony

Gingival pockets [false or relative]

This type of pocket is formed by gingival enlargement without
destruction of the underlying periodontal tissues. The sulcus is
deepened because of the increased bulk of the gingiva.

Periodontal pockets [true or absolute]

This type of pocket occurs with destruction of the supporting
periodontal tissues. Progressive pocket deepening leads to
destruction of the supporting periodontal tissues and loosening and
exfoliation of the teeth.
 A – Gingival
B – Suprabony
C - Infrabony

A B C
There are two types of True pockets:
1] Supra bony [supracrestal] pockets:
Bottom of the pocket is coronal to the
underlying alveolar bone.

2] Infra bony [subcrestal] pockets:

Bottom of the pocket is apical to the
crest of adjacent alveolar bone
Pockets can be classified according to the number of surfaces
involved;
A] Simple: one tooth surface
B] Compound: 2 or more surfaces. Base of the pocket is in direct
communication with the gingival margin along each of involved
surface.
C] Complex: A spiral type pocket that originates on one tooth
surface and twists around the tooth to involve one or more
additional surfaces.

A – simple
B – compound
C - complex
Infrabony pockets may have accompanying
angular [vertical] defects
Vertical/angular defects are those that occur in an
oblique direction, in the bone alongside the root;
the base of the defect is located apical to the
surrounding bone.
Infrabony pockets are classified according to;
1] The depth and width of osseous defects as:
Type 1: Shallow narrow
Type 2: Shallow wide
Type 3: Deep narrow
Type 4: Deep wide

2] The number of remaining walls in the

osseous defect
a] Three wall defect
b] Two wall defect
c] One wall defect
d] Four wall defect
 Diffrences between suprabony and infra bony pockets
Suprabony pockets Infrabony pockets
1] The base of the pocket is 1] The base of the pocket is
coronal to the level of the apical to the crest of the
alveolar bone. alveolar bone.
2] The pattern of destruction 2] The bone destruction pattern
of the bone is horizontal. is vertical [angular]
3]Transeptal fibres are 3]Transeptal fibres are
arranged horizontally in the arranged obliquely in
interproximal areas interproximal areas
4] On the facial and lingual 4]Periodontal
surfaces, the periodontal ligament fibres follow angular
ligament fibres beneath the pattern; extend from the
pocket follow their normal cementum beneath the base of
horizontal – oblique course the pocket along the bone and
over the crest to join with the
outer periosteum.
Clinical Features
1. Bluish red thickened marginal gingiva.
2. Bluish red vertical zone from gingival margin to the
alveolar mucosa.
3. Gingival bleeding and/or suppuration.
4. Tooth mobility and diastema formation.
5. Symptoms—such as localized pain or pain deep ‘in
the bone’.
6. Sometimes radiating pain or sensitivity or sensation
of pressure after eating.
7. Foul taste in localized areas.
8. Sensitivity to hot and cold.
9. Tooth ache in the absence of caries sometimes
present.
Probing is the only reliable method of detecting
pockets.
Pockets are not detected by radiographs.
The periodontal pocket is a soft tissue change.
Radiographs indicate areas of bone loss where pockets are
suspected.

Pathogenesis: Peridontal pockets are caused by micro

organisms and their products, which produce pathologic
tissue changes and deepening of gingival sulcus.

PLAQUE → GINGIVAL INFLAMMATION →

POCKET FORMATION → MORE PLAQUE
FORMATION.
 Deepening of the gingival sulcus may occur by:

 Movement of the gingival margin in coronal

direction.
 Migration of the junctional epithelium apically
and its separation from the tooth surface.
 Combination of both processes.

Transition from normal gingival sulcus to the

pathologic periodontal pocket are associated with
different proportion of bacteria in dental plaque.
Healthy Gingiva—Coccoid,straight rods.
Diseased Gingiva-Spirocheates,motile rods and gm-
ve anerobic bacteria.
Pocket formation starts as an inflammatory change
in the connective tissue wall of gingival sulcus.
The cellular and fluid inflammatory exudate causes
degeneration of the surrounding connective tissue
including gingival fibres.

Two hypothesis regarding collagen loss

1] Collagenases and other lysosomal enzymes from

PMNL and macrophages become extracellular and
destroy collagen.

2] Fibroblasts phagocytize collagen fibres.

Histopathology: Once the pocket is formed the
following microscopic features are present;

The soft tissue wall: The connective tissue is

edematous and densely infiltrated with plasma cells
[approx. 80% and lymphocytes and scattering of
PMNL]
Blood vessels are increased in number, dilated and
engorged.
Connective tissue shows varying degrees of
degeneration and simple or multiple necrotic foci.
In addition to exudative and degenerative changes,
connective tissue presents newly formed capillaries,
fibroblasts and collagen fibres.
Epithelium of the lateral wall of
pocket presents proliferative and
degenerative changes.
Junctional epithelium at the base
of pocket varies as to length,
width and condition of epithelial
cells.
Epithelial buds extend into the
adjacent inflamed connective
tissue.
Progressive degeneration and necrosis of
epithelium leads to ulceration of the lateral wall.
Exposure of underlying markedly inflamed
connective tissue with suppuration.
Bacterial invasion of the apical and lateral areas
of pocket wall may occur.
The balance between destructive and
constructive changes determines clinical
features such as colour, consistency and
surface texture of pocket wall. At the
clinical level former is referred to as oedematous
pocket wall and latter as fibrotic pocket wall.
The root surface wall: changes in cementum can
be classified as;
1] Structural changes
A] Presence of pathologic granules – due to
collagen degeneration.
B] Areas of increased mineralization – due to
exchange of minerals and organic components from
oral cavity.
C] Areas of demineralization related to root
caries.
2] Chemical changes: Development of highly
calcified layer due to absorption of calcium,
phosphorous and fluoride from environment.
3] Cytotoxic changes: Bacterial penetration into
cementum upto cemento dentinal junction;
Endotoxins also detected.
Periodontal disease activity

Periodontal pocket goes through;

Periods of quiescence – inactive period,
characterized by a reduced inflammatory
response with little or no loss of bone and CT
attachment.
Periods of Exacerbation – active period,
characterized by loss of bone and CT attachment
leading to deepening of pockets.
Contents of periodontal pockets
Micro organisms and their products, plaque, gingival
fluid, food remnants, salivary mucin, desquamated
epithelial cells and leucocytes.

If a purulent exudates is present – consists of living

and degenerated necrotic leucocytes, living and dead
bacteria, serum and scant amount of fibrin.

Significance of pus formation: Pus is a common

feature of periodontal disease. It reflects only the
nature of inflammatory changes in pocket wall. It is
no indication of the depth of the pocket or severity of
the destruction.
Extensive pus may occur in shallow pockets, whereas
deep pockets may present little or no pus.
Periodontal pockets are healing lesions

Destructive Constructive

Balance

Periodontal pockets constantly are undergoing

repair and the condition of soft tissue wall results
from interplay of destructive and constructive
tissue changes.
 Relation of gingival recession and bone loss to
pocket depth

Same pocket depth with Different pocket depth

different amounts of with the same amount
recession of recession
How do we measure a periodontal pocket?
The only accurate method of detecting and measuring
periodontal pockets is careful exploration with a
periodontal probe.
Periodontal probes are tapered, rod like instrument
calibrated in millimetres with a blunt, rounded tip.
When measuring a pocket, the probe is inserted with
a firm, gentle pressure to the bottom of the pocket.
The shank should be aligned with the long axis of the
tooth surface to be probed [ie parallel] or is held at 40°
angulation depending upon the contour of the tooth.
The pressure used is 20 gms [20 ponds]
Landmarks for pocket detection
1] Crest (tip) of the marginal gingiva
2] Base of the sulcus (epithelial attachment)
3] CEJ
4] Crest of the alveolar bone
5] Muco gingival line
Clinically, a true pocket is diagnosed when the sulcus
measures 3mm and more with the base of the sulcus
below the CEJ.
A false pocket is diagnosed when the sulcus measures
3mm or more coronally with the base of sulcus at the
CEJ.
Pocket probing
There are two different pocket depths
The biologic [histologic] depth: is the distance between
the gingival margin and the base of the pocket [the
coronal end of the junctional epithelium]; it is measured
by histologic sections.
The clinical [probing] depth: is the distance to which a
periodontal probe penetrates into the pocket.
The depth of penetration of a probe
in a pocket depends on factors such
as;
1] Size and tip of the probe
[thickness of the probe]
2] Direction of probing technique
3] Angle of insertion of the probe
4] Condition of tissues: oedematous
tissue penetration is easy, whereas
fibrous tissue may give resistance.
 Transgingival Probing
•Is useful just prior to flap reflection, to provide
more three dimensional information regarding bony
contours (i.e, the thickness, height and the shape of
the underlying bone)

Procedure
Have to anaesthetise the area first.
The probe is walked along the tissue-tooth interface so
that the operator can feel the bony topography.
The probe is passed horizontally through the tissue to
provide information about the bone.
Pocket reduction surgeries
Objectives:
(1) increase access to the root surface,
allowing the clinician to remove all irritants;
(2) reduce or eliminate pocket depth, making it
possible for the patient to maintain the root
surfaces free of biofilm; and
(3) reshape soft and hard tissues to attain a
harmonious topography.
Pocket Reduction Surgery

• Resective (e.g., gingivectomy, apically

displaced flap, undisplaced flap with or
without osseous resection)

• Regenerative (e.g., flaps with grafts,

membranes)
Critical Zones in Pocket Surgery

Criteria for the selection of a surgical technique for

pocket therapy are based on clinical findings in the
soft tissue pocket wall,
Tooth surface,
underlying bone, and
attached gingiva.
Zone 1: Soft Tissue Pocket Wall
The clinician should determine the
morphologic features, thickness,
and topography of the soft tissue pocket
wall and persistence of
inflammatory changes in the wall.
Zone 2: Tooth Surface

The clinician should identify the deposits on

and alterations of the cementum surface and
determine the accessibility of the root
surface to instrumentation.
Zone 3: Underlying Bone

The clinician should establish the shape and

height of the alveolar
bone next to the pocket wall through careful probing
and clinical
and radiographic examinations.
Zone 4: Attached Gingiva
The clinician should consider the presence or
absence of an
adequate band of keratinized, attached gingiva
when selecting the
pocket treatment method.
The methods for pocket therapy can be classified
as follows:
New attachment techniques offer the ideal result
because they eliminate pocket depth by reuniting the
gingiva with the tooth at a position coronal to the
bottom of the preexisting pocket.

Removal of the pocket wall is the most common

method.
Retraction or shrinkage, Surgical removal of the pocket,
Apical displacement of the flap

Removal of the tooth side of the pocket

Criteria for Selection of the Method of
Surgical Therapy
Characteristics of the pocket: depth, relation to bone, and
configuration
Accessibility to instrumentation, including furcation involvement
Existence of mucogingival problems
Response to phase I therapy
Patient cooperation, including the ability to perform effective
oral hygiene and stop smoking
Age and general health of the patient
Overall diagnosis of the case
Aesthetic considerations
Previous periodontal treatments
Approaches to Specific Pocket Problem
Therapy for Gingival Pockets: Edematous tissue
shrinks after the elimination of local factors, reducing or
totally eliminating pocket depth. Scaling and root planing is
the technique of choice for these cases.

fibrotic wall are not appreciably reduced in depth after

scaling and root planing. These pockets are eliminated or
reduced by surgical therapy.

Therapy for Incipient Periodontitis: In patients with slight or

incipient periodontitis with minimal attachment and bone
loss, the pocket depths are shallow or a moderate depth.
scaling, and root planing when necessary
usually suffices to control the disease.
Therapy for Moderate to Severe Periodontitis in the Anterior Sector

Because the maxillary anterior teeth are important aesthetically,

techniques that cause the least amount of visual root exposure should be
considered.

Nonsurgical therapy is
therefore the technique of choice for the maxillary anterior dentition

In case of surgery- The papilla preservation flap or modified papilla

preservation flap can be used for both purposes and offers a better
postoperative result with less recession and reduced soft tissue crater
formation interproximally.

When the aesthetic outcome is not the primary consideration. the

modified
Widman flap can be selected.

In cases with advanced osseous involvement, bone contouring

may be needed despite the resultant root exposure. The technique
of choice is the apically displaced flap with osseous bone contouring.
PAPILLA PRESERVATION FLAP
MODIFIED WIDMAN FLAP
APICALLY DISPLACED FLAP
APICALLY DISPLACED FLAP
Therapy for Moderate to Severe Periodontitis in Posterior Areas

Surgery is used in the posterior area for enhanced access to the root surface or for
definitive pocket reduction requiring osseous surgery.

Most patients with moderate to severe periodontitis have developed osseous defects.
the papilla preservation flap or modified papilla preservation flap is the technique of
choice.

For osseous defects with no possibility of reconstructive therapy, the technique of choice
is an undisplaced or apically displaced flap with osseous contouring.
THANK YOU
REFERENCE:

CARRANZA -13TH EDITION-TEXTBOOK OF

CLINICAL PERIODONTOLOGY