Gingival surgical

techniquesShazia fathima

IIIrd year

Limited to the gingival region and do not involve underlying osseous structures

• Gingival Curettage

• Gingivectomy

• Gingivoplasty

History

John W Riggs (1811-1885)

In an 1876 paper, Riggs was a strong proponent of the

so-called conservative approach to periodontal therapy.He developed the concept of oral prophylaxis and prevention, advocated for the cleanliness of the mouth, and opposed surgery, which at the time consisted of gingival resection.

1902 –Znamensky

published the classic paper ”Alveolar Pyorrhea – Its pathological anatomy and its radical treatment. He treated Pyorrhea with removal of calculus and also deep curettage of the sockets, using cocaine anesthesia

In 1935, Kronfeld proved that the bone in the periodontal pockets was neither necrotic nor infected but rather destroyed by inflammatory process, and the era of tissue curettage began as the attention was shifted to the soft tissue surrounding the tooth as the source of infection.

Salomon Robiscek (1845-1928)

• He developed a surgical technique consisting of a scalloped continuous gingivectomy excision , exposing the marginal bone for subsequent curettage & remodeling.

• The rationale for the radical treatment was supported by the authors such as Neuman, Widman , Robicsek ,Zemsky , Ceszynki and Nodine who popularized the surgical procedures for the elimination of periodontal pocket.

GINGIVAL CURETTAGE

Introduction

Bacterial Plaque causes the formation of Periodontal Pockets and resorption of alveolar bone due to apical migration of Junctional Epithelium

Treatment Of Periodontal Pockets

Pocket Reduction Pocket Elimination

Definition • The term "gingival curettage" implies directing an

operative instrument against the gingival wall of the periodontal pocket in order to remove the ulcerated epithelium covering the sulcus. Thus, curettage is the conversion of a chronic inflammatory ulcer in the gingival wall of the pocket into a surgical wound - ( Nestor & Lopez ,1977)

• The word curettage is used in periodontics to mean the scraping of the gingival wall of a periodontal pocket to separate diseased soft tissue - (Carranza 10th edition )

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•Terminology -

• Gingival curettage – Removal of the inflammed soft tissue lateral to the pocket wall.

• Subgingival curettage- Procedure that is performed apical to the epithelial attachment, severing the connective tissue attachment down to the osseous crest.

• Inadvertent curettage- Some degree of curettage is done unintentionally when scaling and root planing is performed.

Rationale For Curettage• Accomplishes the removal of chronically

inflamed granulation tissue that forms lateral wall of periodontal pocket.

Inflamed Granulation Tissue

Barrier to the attachment of new fibers

Root Planing

Pocket pathologic changes resolve

It has been shown that scaling and root planing with additional curettage do not improve the condition of the periodontal tissues beyond the improvement resulting from scaling and root planing alone.

• Curettage may also eliminate all or most of the epithelium that lines the pocket wall & underlying Junctional Epithelium

- Moskow BS 1964, Beube FE 1953, Sato M 1960

Curettage and Esthetics

• In the past, pocket elimination was the primary goal of therapy, and little regard was given to the esthetic result. Maximal, rapid shrinkage of gingival tissue was the aim to eliminate the pocket.

• Currently, esthetics is a major consideration of therapy, particularly in the anterior maxilla (teeth #6-11), and requires preservation of the interdental papilla.

• When reconstructive therapy is not possible, every effort should be made to minimize shrinkage or loss of interdental papilla

• Compromise Therapy – Avoiding Gingival Curettage

• Papilla Preservation Technique

• Root Planing apical to the base of the pocket

• Another important precaution involves root planing apical to the base of the pocket. The removal of the junctional epithelium and disruption of the connective tissue attachment expose the non-diseased portion of the cementum.

• Root planing in this area of non-diseased cementum may result in excessive shrinkage of the gingiva, increasing recession or requiring "new attachment" where no disease previously existed.

Indications For Curettage

• Very Limited

• They can be used after SRP for the following purposes:

Can be performed as a part of new attachment attempts in moderately deep intrabony pockets in accessible areas where a type of “closed” surgery is deemed advisable.

Non definitive procedure to reduce inflammation or when other surgical procedures are contra-indicated.

On recall visits – Ramfjord 1979

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Contraindications :

• Deep pockets ≥ 5mm• Furcation involvements• Medically compromised patient

Procedure

Basic Technique

• Curettage does not eliminate the causes of inflammation and therefore should be preceded by SRP.

• It requires local anesthesia.

The curette is selected so that the cutting edge is against the tissue (e.g., Gracey #13-14 for mesial surfaces, Gracey #11-12 for distal surfaces). Curettage can also be performed with a 4R-4L Columbia Universal curette. The instrument is inserted so as to engage the inner lining of the pocket wall and is carried along the soft tissue, usually in a horizontal stroke .The pocket wall may be supported by gentle finger pressure on the external surface. The curette is then placed under the cut edge of the junctional epithelium to undermine it.

Gingival curettage performed with a

horizontal stroke of the curette.

In subgingival curettage, the tissues attached between the bottom of the pocket and the alveolar crest are removed with a scooping motion of the curette to the tooth surface.

The area is flushed to remove debris, and the tissue is partly adapted to the tooth by gentle finger pressure. In some cases, suturing of separated papillae and application of a periodontal pack may be indicated.

Subgingival curettage.

A,Elimination of pocket

lining. B,Elimination of

junctional epithelium and

granulation tissue.

C, Procedure completed.

Other Techniques • Other techniques for gingival curettage

include 1. The excisional new attachment

procedure, 2. Ultrasonic curettage, and 3. The use of caustic drugs.

EXCISIONAL NEW ATTACHMENT PROCEDURE (ENAP)

ENAP is the surgical procedure in which an internal bevel incision is made to remove the epithelial lining of the crevice and the junctional epithelium, allowing root visibility

Definitive subgingival curettage performed with knife

Developed by the U.S Naval Dental Corps based on studies by Yukna and colleagues (1976),

Gain new attachmentDecrease probing depth

Access root surface

1. After anesthesia, an internal bevel incision is given from the margin of the free gingiva apically to a point below the bottom of the pocket. (the intention is to cut the inner portion of the soft tissue wall of the pocket , all around the tooth

Excisional new attachment procedure.

A, Internal bevel incision to point below

bottom of pocket.

B, After excision of tissue, scaling and

root planing are performed.3.Approximate the wound edges; if they do not meet passively, recontour the bone until good adaptation of the wound edges is achieved. Place sutures and a periodontal dressing.

2. Remove the excised tissue with a curette and perform root planing on all exposed cementum to achieve a smooth hard surface.

Author Studies Result

Yukna et al,1976 Excisional new attachment procedure was used to treat 75 suprabony pockets on 32 teeth in 9 patients

One-year postoperative -mean pocket reduction from 4.7 mm to 2.0 mm, of which 2.1 mm (77%) was new attachment and 0.6 mm was recession.

Yukna and Williams Jr,1980

Patients treated with the Excisional New Attachment Procedure were evaluated 5 years or more following the procedure

An overall mean net gain in clinical attachment of 1.5 mm was found at 5 years after treatment, and probing depths approached 3.0 mm

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ENAP ModificationIn 1977, Fredi and Rosenfeld modified the

technique by advocating a partial-thickness inverse beveled incision down to the crest of bone to completely remove tissue about the periodontal ligament. The flaps were then sutured at the presurgical height . The technique is basically the same in all other aspects

A. Initial incision made to the crest of bone of the pocket

B. Inner wall removed down to the crest of bone & periodontal ligament

C. Healed tissue

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• The use of ultrasonic devices has been recommended for gingival curettage.• When applied to the gingiva of experimental animals, ultrasonic vibrations disrupt tissue continuity, lift off epithelium, dismember collagen bundles, and alter the morphologic features of fibroblast nuclei.

• Ultrasound is effective for debriding the epithelial lining of periodontalpockets. It results in a narrow band of necrotic tissue (microcauterization), which strips off the inner lining of the pocket

The Morse scaler-shaped and rod-shaped ultrasonic instrumentsare used for this purpose.

Nadler H-1962 found ultrasonic instruments to be as effective as manualinstruments for curettage but resulted in less inflammationand less removal of underlying connective tissue.

Ultrasonic Curettage

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Since early in the development of periodontal procedures, the use of caustic drugs has been recommended to induce a chemical curettage of the lateral wall of the pocket or even the selective eliminationof the epithelium.

Drugs such as :sodium sulfidealkaline sodium hypochlorite solution (Antiformin),phenol

These drugs were discarded after studies showed their ineffectiveness. The extent of tissue destruction with these drugs cannot be controlled,and they may increase rather than reduce the amount of tissue to be removed by enzymes and phagocytes (Kenneth – 1981) (Lorraine et al-1986)

Caustic Drugs

Healing After Curettage

• Immediately after curettage, blood clot fills the pocket area which is totally or partially devoid of epithelial lining.

• Hemorrhage is also present in tissues with dilated capillaries and abundant PMN’s appear shortly thereafter on the wound surface. This is followed by a rapid proliferation of granulation tissue, with decrease in number of small blood vessels.

• Restoration of sulcus generally requires 2-7 days and restoration of JE in animals occur in 5 days.

• Immature collagen fibres appear within 21 days.

• Healthy gingival fibers inadvertently severed from tooth and tears in epithelium are repaired in healing process.

• Healing results in the formation of long JE with no CT in humans -Waerhaugh 1978

• In some cases long JE is interrupted by “Windows” of CT attachment - Caton JC 1979

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CLINICAL APPEARANCE AFTER SCALING AND CURETTAGE

Immediately after scaling and curettage, the gingiva appearshemorrhagic and bright red.

After 1 week, The gingiva appears reduced in height owing to an apical shift in the position of the gingival margin. The gingiva is also slightly redder than normal, but much lesser than on previous days.

After 2 weeks The normal color, consistency, surface texture, and contour

of the gingiva are attained, and the gingival margin is well adapted to the tooth

GINGIVAL  CURETTAGE – RELEVANCE

•Gingival curettage and debridement of soft tissue wall of the pocket as an adjunct to SRP seems to offer no advantage in the initial healing response over SRP alone. •Removal vs non removal of granulation tissue during flap surgery and non surgical therapy (SRP) was studied by Lindhe & Nyman (1985). The results failed to show an advantage of granulation tissue removal.•Studies provide  convincing evidence that SRP alone produce results clinically equivalent to curettage plus SRP.

• The various methods used for epithelial removal show that they have no advantage over mechanical instrumentation with curette.

• Therefore gingival curettage by whatever method performed should be considered as a procedure that has no additional benefit to SRP alone in treatment of chronic periodontitis.

AAP- statement regarding gingival curettage

• 1989 world workshop in clinical periodontics concluded that curettage had ‘ no justifiable application during active therapy for chronic adult periodontitis’

• Curettage is a procedure which provides historic interest in the evolution of periodontal therapy but has no current clinical relevance in the treatment of chronic periodontitis

(AAP Academy Report 2002)

GINGIVECTOMY

Gingivectomy

• Grant et al 1979 - Excision of soft tissue wall of pathologic periodontal pocket.

• Gingivectomy means excisions of the gingiva.

• By removing the pocket wall, Gingivectomy provides visibility and accessibility for complete calculus removal and thorough smoothing of roots, creating a favorable environment for gingival healing and restoration of physiological contour.

The gingivectomy technique was widely performed in the past. Improved understanding of healing mechanisms and the development of more sophisticated flap methods have relegated the gingivectomy to a lesser role in the current repertoire of available techniques. However, it remains an effective form of treatment when indicated .

Results obtained by treating a suprabony pocket with gingivectomy. A, Before treatment. B, After treatment.

Indications

• Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm.

• Elimination of gingival enlargements. • Elimination of suprabony periodontal

abscesses. Glickman - 1956

Contraindications• The need for bone surgery or examination of the

bone shape and morphology. • Situations in which the bottom of the pocket is

apical to the mucogingival junction. • Esthetic considerations, particularly in the

anterior maxilla.

Various techniques of

GINGIVECTOMY

Surgical gingivectomy

Gingivectomy by electrosurgery

Laser gingivectomy

Gingivectomy with chemosurgery

Surgical Technique• Step 1: The pocket on each surface are

explored with a periodontal probe and marked with a pocket marker. Each pocket is marked in several areas to outline its course on each surface.

Step 2: • Periodontal knives (Kirkland knives)• Orban periodontal knives • Bard-Parker knives # 11 and # 12 and

scissors.

• The incision is started apical to the points marking the course of the pocket (Orban 1952) and is directed coronally to a point between the base of the pocket and crest of the bone.

• It should be as close as possible to the bone

• Discontinuous or continuous incisions may be used

• Incision should be beveled at 450 to the tooth surface

Step 3: • Remove excised pocket wall• Clean the area• Examine the root surface

Step 4 : • Curette granulation tissue• Remove any remaining necrotic

cementum or calculus

Step 5:• Cover the area with surgical pack

• Robicsek (1884) – Straight incision technique

• Zentler (1918) – Scalloped incision technique

PERIODONTAL KNIVES

A, Discontinuous incision apical to bottom of thepocket indicated by pinpoint markings. B, Continuous incision beginson the molar and extends anteriorly without interruption

• Initially, formation of a protective surface clot.

• Underlying tissue becomes acutely inflamed,

with some necrosis.

• The clot is then replaced by granulation

tissue.

Healing after GINGIVECTOMY

• By 24 hours, there is an increase in new connective tissue

cells mainly angioblasts, below the surface of inflammation.

• By the 3rd day, numerous young fibroblasts are located in

the area.

• This highly vascularized connective tissue grows coronally,

creating a new, free gingival margin and sulcus.

• After 12 to 24 hours, epithelial cells at the margins of

the wound start migrating over the granulation

tissue.

• Epithelial activity reaches a peak in 24 to 36 hours.

• After 5 to 14 days, surface epithelialization is

generally complete.

• Complete repair takes about 1 month.

GINGIVECTOMY BY electrosurgery

ADVANTAGES:

Control of hemorrhage.

Adequate contouring of the tissue.

DISADVANTAGES:

• Cannot be used in patients who have poorly shielded

cardiac pacemakers.

• Treatment causes unpleasant odor.

• If the electro surgery point touches the bone,

irreparable damage can be done.

• The heat generated by injudicious use can

cause tissue damage and loss of

periodontal support when the electrode is

used close to the bone

• when electrode touches the root, areas of

cementum burn are produced.

Technique • Removal of gingival enlargements and gingivoplasty is

performed with the needle electrode.

• Small, ovoid loop or the diamond shaped electrodes are used

for festooning.

• In all reshaping procedures, electrode is activated and moved

in a concise “shaving” motion.

• For hemostasis, the ball electrode is used.

For Acute Periodontal Abscess◘ Drainage with needle electrode without

exerting painful pressure◘ Followed by regular procedure

• Frenum – Loop electrode• Acute Pericornitis – Bent needle electrode

Healing After Electrosurgery

• Fisher SE 1983 – No significant differences

• Pope JW 1968 – Delayed healing

• Glickman J 1970 – Necrosis , Sequestration , Loss of bone height , furcation exposure & tooth mobility

Laser GINGIVECTOMY

The lasers most often used in dentistry are

the carbon dioxide (CO2) and

neodymium:yttrium-aluminum-garnet

(Nd:YAG) with the wavelength of 10,600nm

and 1064nm respectively.

• The healing is delayed compared with healing

after conventional scalpel gingivectomy.

• Requires precautions to avoid reflecting the beam

on instrument surfaces, which could result in injury

to neighboring tissues and eyes of the operator.

Gingivectomy By Chemosurgery

• 5 % paraformaldehyde – Orban B 1942• Pottasium hydroxide – Loe 1961 Disadvantages:

• Depth of action cannot be controlled• Gingival remodelling cannot be accomplished• Epithelialization & reformation of JE occurs

slowly – Tonna E 1967• Not recommended

Gingivoplasty Recontouring of the gingiva in the absence of pockets

Used to correct deformities like:

• Gingival clefts & craters

• Shelf like interdental papilla - ANUG

• Gingival enlargements

Instruments:

• Periodontal knife & scalpel

• Rotary coarse diamond stones

• Electrodes

Procedure:

• Tapering the Gingival Margin

• Creating scalloped marginal outline

• Thinning of attached gingiva

• Creating vertical interdental grooves

• Shaping interdental papilla

C. Gingivoplasty. D. 8 weeks postsurgically.

Conclusion

Current understanding of disease etiology & therapy limits the use of these techniques , but their place in

surgical therapy is essential….

thankyou

References

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• Carranza 10th edition • Lindhe J, Nyman S. The effect of plaque control and

surgical pocket elimination on the establishment and maintenance of periondontal health. A longitudinal study of periodontal therapy in cases of advanced disease. J Clin Periodontol 1975;2:67–79.

• Stern T, Everett F, Robicsek K. S. Robicsek a pioneer in the surgical treatment of periodontal disease. J Periodontol 1965;36:265–268.

• The American Academy of Periodontology; Glossary of Periodontal Terms, 3rd ed. Chicago; The American Academy of Periodontology; 1992

• The american academy of periodontology statement regarding gingival curettage – JOP 2002