Gingival surgical techniques/Gingivectomy
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Gingival surgical techniques/Gingivectomy
- 1. PRESENTED BY: DR. THASLIM FATHIMA FIRST YEAR POSTGRADUATE DEPARTMENT OF PERIODONTOLOGY
- 4. “• GINGIVAL CURETTAGE The word curettage is used in periodontics to mean the scraping of the gingival wall of a periodontal pocket to remove diseased soft tissue. Scaling and root planing may inadvertently include various degrees of curettage. SCALING PLANING
- 5. Subgingival curettage refers to the procedure that is performed apical to the junctional epithelium and that severs the connective tissue attachment down to the osseous crest.
- 6. INADVERTENT CURETTAGE Some degree of curettage is accomplished unintentionally during scaling and root planing and is referred to inadvertent curettage. This chapter refers to the intentional curettage performed during the same visit as scaling and root planing or as a separate procedure to reduce pocket depth by enhancing gingival shrinkage, new connective tissue attachment, or both.
- 7. Curettage accomplishes the removal of the chronically inflamed granulation tissue that forms in the lateral wall of the periodontal pocket. RATIONALE • This tissue, in addition to the usual components of granulation tissues,contains areas of chronic inflammation, and it may also contain pieces of dislodged calculus and bacterial colonies. R
- 8. • The existing granulation tissue is slowly resorbed, and the bacteria present in the tissue without replenishment of their numbers from the plaque in the pocket are destroyed by the defense mechanisms of the host
- 10. • However, opinions differ with regard to whether scaling and curettage consistently remove the pocket lining and the junctional epithelium Some investigators report that scaling and root planing tear the epithelial lining of the pocket without removing either it or the junctional epithelium. Others claim that both epithelial structures and sometimes the underlying inflamed connective tissue are removed by curettage Some investigators have reported that the removal of the pocket lining and the junctional epithelium by curettage is not complete.
- 11. “ • Gingival curettage as a separate procedure has no justifiable application during active therapy for chronic adult periodontitis. • Gingival curettage is not indicated if new attachment is the goal of therapy. The consensus report of the proceedings of the World Workshop in Clinical Periodontics (1989) came to the following conclusions
- 12. CURETTAGE AND AESTHETICS • Rapid shrinkage of the gingival tissue was the goal to eliminate the pocket. • Currently, aesthetics is a major consideration of therapy, especially in the maxillary anterior area, and every effort is made to minimize gingival tissue shrinkage and to preserve the interdental papilla. • Compromise therapy is feasible in the anterior maxilla. This therapy consists of thorough subgingival root planing while attempting to not detach the connective tissue attachment beneath the junctional epithelium. • Gingival curettage should be avoided.
- 14. “Avoid root planing apical to the base of the pocket to the osseous crest. The removal of the junctional epithelium and the disruption of the connective tissue attachment exposes the non- diseased portion of the cementum. Root planing and the removal of the non-diseased cementum may result in excessive shrinkage of the gingiva, which results in increased gingival recession
- 15. 1. Curettage can be performed as part of new attachment attempts in moderately deep intrabony pockets located in accessible areas in which a nonflap type of “closed” surgery is indicated. INDICATIONS 2. Curettage can be attempted as a nondefinitive procedure to reduce inflammation when aggressive surgical techniques (e.g., flaps) are contraindicated in patients as a result of their age, systemic problems, psychologic problems, or other factors… 3. Curettage is also frequently performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket depth, especially where pocket reduction surgery has previously been performed.
- 16. Edematous and inflamed tissues Shallow pockets Suprabony pockets As part of initial preparation prior to open surgical procedures in an attempt to achieve tissue quality that can be handled easily INDICATIONS CONTRAINDICATIONS
- 17. Procedure cutting edge is against the tissue
- 18. scooping motion
- 21. Excisional New Attachment Procedure • The excisional new attachment procedure has been developed and used by the US Naval Dental Corps. • It is a definitive subgingival curettage procedure that is performed with a knife. • The ENAP, as outlined by Yukna and colleagues (1976), was an attempt to overcome some of the limitations of closed gingival curettage and gain new attachment in areas of suprabony pockets. • It was developed to ensure complete removal of sulcular epithelium, epithelial attachment, granulated and inflamed connective, subgingival calculus, and softened cementum. • Basically, it is curettage with a surgical blade, which increases access and visibility with minimal tissue reflection.
- 22. PROCEDURE
- 23. ENAP
- 24. Indications Contraindictions Advantages Disadvantages
- 26. ULTRASONIC CURETTAGE Ultrasound is effective for debriding the epithelial lining of periodontal pockets. This 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 instruments are used for this purpose. Some investigators found ultrasonic instruments to be as effective as manual instruments for curettage and that such tools resulted in less inflammation and less removal of underlying connective tissue.
- 27. CAUSTIC DRUGS
- 28. Healing After Scaling and Curettage H Blood clot Hemorrhage is also present in the tissues with dilated capillaries and abundant polymorphonuclear leukocytes, which appear on the wound surface Rapid proliferation of granulation tissue
- 29. Healing After Scaling and Curettage H • restoration and epithelialization of the sulcus2 to 7 days • restoration of the junctional epithelium 5 days • Immature collagen fibers appear 21 days
- 31. “Clinical Appearance After Scaling and Curettage
- 34. Robicsek (1884) Grant et al. (1979) GINGIVECTOMY H
- 36. Gingivectomy
- 37. Gingivoplasty • In gingivoplasty, the tissue is thinned interproximally to produce a more harmonious contour, with interproximal sluiceways for the easy passage of food. • Gingivectomy and gingivoplasty are usually performed at the same time.
- 38. Rationale R
- 39. 1. Suprabony pockets 2. An adequate zone of keratinized tissue 3. Pockets greater than 3 mm 4. When bone loss is horizontal and no need exists for osseous surgery 5. Gingival enlargements 6. Areas of limited access 7. Unesthetic or asymmetric gingival topography 8. For exposure of soft tissue impaction to enhance eruption 9. To facilitate restorative dentistry 10. To establish physiologic and gingival contours post–acute necrotizing ulcerative gingivitis and flap procedures
- 40. 1. An inadequate zone of keratinized tissue 2. Pockets that extend beyond the mucogingival line 3. The need for osseous resection 4. Highly inflamed or edematous tissue 5. Areas of esthetic compromise 6. Shallow palatal vaults and prominent external oblique ridges 7. Treatment of intrabony pockets 8. Patients with poor oral hygiene
- 42. Gingivectomy After initial healing, the zone of attached tissue can be assessed properly. At the time of operation, adequate local anesthesia is given. A vasoconstrictor should be used for control of hemorrhage, especially since healing is by secondary intention Under anesthesia, the pockets are probed to check their depth and to ensure that they do not extend beyond the mucogingival junction. By sounding, the osseous topography is determined and the need for osseous surgery is determined.
- 44. Three points (mesial, distal, and buccal) are marked on each buccal and lingual surface held parallel POCKET MARKING ---
- 45. INCISIONS
- 51. “• The final contour of the tissue is established using scissors, tissue nippers, or diamond stones. • This final contouring, or gingivoplasty, is used to thin the tissue on the interradicular surface and establishes a more fluid contour. • The healed tissue will be thin, with a scalloped architecture that flows smoothly from the interdental areas onto the interradicular surfaces for easy passage of food. Gingivoplasty
- 55. Edentulous, Retromolar, and Tuberosity Areas The edentulous area between the teeth is noteworthy only in that the incision should stretch the entire length of the space. Pockets tend to reform if the incision is limited to an area adjacent to the teeth.
- 58. Common Reasons for Failure 8. Failure to eliminate or control the predisposing factors 9. Inaccessible interdental spaces 10. Loose dressings 11. Lost dressings 12. Insufficient use of dressings 13. Failure to prescribe stimulators or rubber tipping for interproximal use 14. Failure to use stimulators or a rubber tip 15. Failure to complete treatment
- 59. (1) Gingival clefts and craters 2) Craterlike interdental papillae caused by acute necrotizing ulcerative gingivitis 3) Gingival enlargements.
- 60. HEALING AFTER SURGICAL GINGIVECTOMY Blood clot granulation tissue increase in new connective tissue cells young fibroblasts highly vascular granulation tissue grows coronally creates a new free gingival margin and sulcus.
- 61. Capillaries derived from the blood vessels of the periodontal ligament migrate into the granulation tissue, and, within 2 weeks, they connect with the gingival vessels. After 12 to 24 hours, epithelial cells at the margins of the wound begin to migrate over the granulation tissue, thereby separating it from the contaminated surface layer of the clot. Epithelial activity at the margins reaches a peak after 24 to 36 hours. The new epithelial cells arise from the basal and deeper spinous layers of the epithelial wound edge and migrate over the wound over a fibrin layer that is later resorbed and replaced by a connective tissue bed. The epithelial cells advance by a tumbling action, with the cells becoming fixed to the substrate by hemidesmosomes and a new basement lamina.
- 62. 5 to 14 days 1 month 7 weeks
- 63. GINGIVECTOMY BY ELECTROSURGERY Advantages Electrosurgery permits an adequate contouring of the tissue and controls hemorrhage
- 66. T e c h n i q u e
- 68. Some investigators report no significant differences in gingival healing after resection by electrosurgery and resection with periodontal knives. Other researchers find delayed healing, greater reduction in gingival height, and more bone injury after electrosurgery. HEALING AFTER ELECTROSURGERY • However; when used for deep resections close to bone, electrosurgery can produce gingival recession, bone necrosis and sequestration, loss of bone height, furcation exposure, and tooth mobility, which do not occur with the use of periodontal knives
- 72. LASERS ADVANTAGES & DISADVANTAGES Better visualization of cutting Patient acceptance Detoxification of a wound Less invasive Minimal wound contraction and scarring Generates excessive temperature changes in hard tissues Can induce cellular damage and osseous resorption ≥60° C (140° F) result in tissue necrosis Overexposure--tissue damage and destruction of the periodontium
- 74. Periodontal Esthetic Applications and Functional Crown Lengthening • Esthetic applications for gingivectomy and gingivoplasty procedures allow delicate tissue shaping. • Some clinicians advocate the use of lasers for crown-lengthening procedures. • For functional crown lengthening involving osseous contouring, the use of laser is controversial. • Additionally, laser therapy can potentially offer extreme precision and may be easier than using a scalpel.
- 75. “ Techniques to remove the gingiva using chemicals, such as 5% paraformaldehyde to or potassium hydroxide, have been described in the past but are not currently used. They are presented here to provide a historical perspective. Gingivectomy by Chemosurgery
- 76. The use of chemical methods therefore is not recommended
- 77. Comparative evaluation of healing after gingivectomy with electrocautery and laser • Symmetrical gingival hyperplasia were treated with electrocautery and laser on each side. • Parameters assessed were duration of surgery, bleeding, postoperative pain and healing. • Both techniques can be used to remove gingival overgrowth with equal efficiency and wound healing capacity. • There is no advantage of diode laser over electrocautery in performing gingivectomy.
- 79. “
- 80. “
- 85. THANK YOU
Notas del editor
- Periodontal pocket reduction surgery that are limited to the gingival tissues only and not involving the underlying osseous structures, without the use of flap surgery, can be classified as gingival curettage and gingivectomy. The current understanding of disease etiology and therapy limits the use of both techniques, but their place in surgical therapy is essential.
- SCALING refers to the removal of deposits from the root surface, whereas PLANING means smoothing the root to remove infected and necrotic tooth substance. However, they are different procedures with different rationales and indications. Both should be considered separate parts of periodontal treatment.
- It should also be understood that some degree of curettage is accomplished unintentionally during scaling and root planing and is referred to inadvertent curettage. This chapter refers to the intentional curettage performed during the same visit as scaling and root planing or as a separate procedure to reduce pocket depth by enhancing gingival shrinkage, new connective tissue attachment, or both
- granulation tissues (i.e., fibroblastic and angioblastic proliferation) The latter may perpetuate the pathologic features of the tissue and hinder healing
- (This should not be confused with the elimination of granulation tissue during flap surgery.The reason for the latter is to remove the bleeding tissue that obstructs visualization and prevents the necessary examination of the root surface and the bone morphology.Thus, the removal of granulation tissue during surgery is accomplished for technical rather than biologic reasons.)
- Curettage for this purpose is still valid, particularly when an attempt is made for new attachment, as occurs in intrabony pockets.
- This conclusion was arrived at due to the difficulty of assessing what if any the beneficial effects of curettage were since they are almost always combined with root instrumentation.
- An awareness of aesthetics in periodontal therapy has become an integral part of care in the modern practice of periodontics. In the past, pocket elimination was the primary goal of therapy, and little regard was given to the aesthetic result.
- There are many instances in which a surgical flap is necessary for access to the root surface for scaling and root planing. A surgical technique that has been specially designed to minimize gingival recession and preserve the interdental papilla is the papilla preservation technique
- Another important precaution is to avoid root planing apical to the base of the pocket to the osseous crest.
- 2…. It should be understood that, in these patients, the goal of pocket elimination is compromised, and their prognosis is impaired. The clinician should attempt this approach only when the indicated surgical techniques cannot be performed and both the clinician and the patient have a clear understanding of its limitations
- Cohen—CI Fibrotic tissue Deep pockets Furcation involvements Indi: Progressive attachment or alveolar bone loss Increased levels of pathogenic microorganisms
- Curettage does not eliminate the causes of inflammation (i.e., bacterial plaque and deposits). Therefore, curettage should always be preceded by scaling and root planing, which is the basic periodontal therapy procedure. The use of local infiltrative anesthesia for scaling and root planing is optional. However, gingival curettage will always require some type of local anesthesia.
- Other techniques for gingival curettage include the excisional new attachment procedure, ultrasonic curettage, and the use of caustic drugs
- SATO;;Incision techniques for flap preparation are the coronally directed incision (external bevel incision) and the apically directed incision.' 1° The most frequently used and basic incision in periodontal surgery is the apically directed incision. The internal bevel incision is especially important. See Tables 1-10 and 1-11 for descriptions of the sulcular incision and the apically directed internal bevel incision.
- Car and lindhe
- The excisional new attachment procedure technique is as follows:
- After the exicison of tissue,Scaling and rp are performed.
- Modified ENAP Modification In 1977, Fredi and Rosenfeld modified the technique by advocating a partial-thickness inversebeveled incision down to the crest of bone (Figure 4-7A) to completely remove tissue about the periodontal ligament (Figure 4-7B). The flaps were then sutured at the presurgical height (Figure 4-7C). The technique is basically the same in all other aspects
- Excisional new attachment procedure. A and B, Preoperative views showing suprabony pockets and an adequate zone of keratinized gingiva. C, A scalloped labial incision is made at the crest of the gingiva. D, The incision is carried down to the base of the pocket. E and F, Facial and cross-sectional views showing that the interproximal papillae are partially dissected to remove the thick triangular wedge of tissue. In effect, the papillae are treated as a partial-thickness flap. G, The papillae are reflected slightly for access and the root is scaled and root planed. H, Cross-sectional view showing the inflamed inner wall removed and the root scaled. I, Flap sutured at presurgical height. J, Healed tissue with pockets eliminated as a result of shrinkage and tight adaptation to the tooth.
- When applied to the gingiva of experimental animals, ultrasonic vibrations disrupt tissue continuity, lift off the epithelium, dismember collagen bundles, and alter the morphologic features of fibroblast nuclei.
- Immediately after curettage, a blood clot fills the pocket area, which is totally or partially devoid of epithelial lining. Hemorrhage is also present in the tissues with dilated capillaries and abundant polymorphonuclear leukocytes, which appear on the wound surface. This is followed by a rapid proliferation of granulation tissue with a decrease in the number of small blood vessels as the tissue matures.
- The restoration and epithelialization of the sulcus generally require 2 to 7 days,and restoration of the junctional epithelium occurs in animals as early as 5 days after treatment. Immature collagen fibers appear within 21 days
- In some cases, this long epithelium is interrupted by “windows” of connective-tissue attachment.
- Immediately after scaling and curettage, the gingiva appears hemorrhagic and bright red. After 1 week, the gingiva appears reduced in height as a result of an apical shift in the position of the gingival margin. The gingiva is also darker red than normal, but it is much less red than it will have been on previous days. After 2 weeks and with proper oral hygiene, the normal color, consistency, surface texture, and contour of the gingiva are attained, and the gingival margin is well adapted to the tooth.
- Robicsek (1884) and,later,Zentler (1918)Described G. Inn the following way
- is the excisional removal of gingival tissue for pocket reduction or elimination.
- 1. Healing by secondary intention 2. Bleeding postoperatively 3. Loss of keratinized gingiva 4. Inability to treat underlying osseous deformities
- The gingivectomy procedure as it is employed today was first described in 1951 by Goldman
- Periodontal Knives (Gingivectomy Knives). The Kirkland knife is representative of the knives that are typically used for gingivectomy. These knives can be obtained as either doubleended or single-ended instruments. The entire periphery of these kidney-shaped knives is the cutting edge,.. Interdental Knives. The Orban knife (nos. 1 and 2; Figure 55-6, B) and the Merrifield knife (nos. 1 through 4) are examples of knives that can be used for interdental areas. These spear-shaped knives have cutting edges on both sides of the blade, and they are designed with either double-ended or single-ended blades.
- The pocket marker must not be tilted or the incision will be too deep or too shallow
- No real differences exist between incisions except that one is an interrupted incision ending in the papillary area of each successive tooth until the incision is completed.
- Figure 5-1M shows the correct and incorrect incision placements.
- cohen
- Lindhe If a gingivectomy has been performed, the cut surface is covered with a friable meshwork of new epithelium, which should not be disturbed. The facial and lingual mucosa may be covered with a grayish-yellow or white granular layer of food debris that has seeped under the pack. This is easily removed with a moist cotton pellet.
- 22MONTHS
- The complete procedure is outlined clinically in Figure 5-2, and the results that can be attained are shown in Figure 5-3.
- FIGURE 5-2. Gingivectomy and gingivoplasty procedures. A, Before treatment. B, Bleeding points show marked pockets. Probe shows 4 to 5 mm pockets. C, Initial incision with a periodontal knife angled at 45°. D, A no. 15 scalpel blade used for the initial incision. E, Orban knife used to release interdental tissue, F, Heavy scalers used to remove incised tissue. G, Tissue removed. Note the ledge of beveled tissue. H, Scissors used for reduction of the ledge and gingivoplasty. I, Small diamonds are used to blend the tissue, especially interproximally on bulky tissue. J, Tissue nippers may be used for gingivoplasty. Note how tissue has been thinned and blended (K). L, Healed tissue 6 months later.
- The initial response after gingivectomy is the formation of a protective surface blood clot. The underlying tissue becomes acutely inflamed with necrosis. The clot is then replaced by granulation tissue. In 24 hours, there is an increase in new connective tissue cells, which are mainly angioblasts beneath the surface layer of inflammation and necrotic tissue. By the third day, numerous young fibroblasts are located in the area. The highly vascular granulation tissue grows coronally and creates a new free gingival margin and sulcus
- The flow of gingival fluid in humans is initially increased after gingivectomy, and it diminishes as healing progresses.Maximal flow is reached after 1 week, which coincides with the time of maximal inflammation.
- Therefore the use of electrosurgery should be limited to superficial procedures such as removal or gingival enlargements, ;Gingivoplasty; relocation of frenum and muscle attachments, and incision of periodontal abscesses and pericoronal flaps. Extreme care should he exercised to avoid contacting the tooth surface.
- For cases of acute pericoronitis, drainage may be obtained by incising the flap with a bent-needle electrode. A loop electrode is used to remove the flap after the acute symptoms subside.
- There appears to be little difference in the results obtained after shallow gingival resection with electrosurgery and that with periodontal knives.
- They must be combined with other types of visible lasers tor the beam to be seen and aimed. Currently, lasers are used in periodontal therapy for (1) surgical procedures such as gingivectomy and osseous crown lengthening, (2) nonsurgical therapy, and (3) the surgical management of pathological changes resulting from periodontal disease The wavelengths of the diode (655 to 980 nm) and Nd : YAG (1064 nm) The CO2 laser has a very long wavelength (10,600 nm) with an affinity for water. The CO2 laser should only be used with soft tissue procedures. wavelengths of erbium : YAG (Er : YAG) (2790 nm) and erbium, chromium : yttrium (Er,Cr : YSGG) (2780 nm) lasers have a positive affinity for both water and hydroxyapatite
- There are many advantages to using laser therapy, including better visualization of cutting, patient acceptance, and the detoxification of a wound. Other advantages are less invasive surgery to gain access and minimal wound contraction and scarring. conversely, lasers can also generate excessive temperature changes in hard tissues as reported from the studies by Eriksson and Albrektsson.24 The exposure of bone to temperatures ≥47° C (116.6° F) can induce cellular damage and osseous resorption. Extreme temperature levels of ≥60° C (140° F) result in tissue necrosis Overexposure of laser energy has been the basis for reports of tissue damage and destruction of the periodontium
- Several types of laser wavelengths have been reported to be effective for soft tissue procedures.4,48,49 Some of the positive aspects of laser therapy are good visibility during the surgical procedure as a result of coagulation, hemostasis, and minimal tissue damage adjacent to the laser wound are also advantages. Additionally, laser therapy can potentially offer extreme precision and may be easier than using a scalpel.
- To evaluate whether laser has got any advantage over electrocautery in performing gingivectomy procedure Praveen Kumar,a Vidya Rattan,b and Sachin Raic,∗J Oral Biol Craniofac Res. 2015
- In general, small areas (i.e., up to six teeth) of drug-induced gingival enlargement with no evidence of attachment loss (and therefore no anticipated need for osseous surgery) can be effectively treated with the gingivectomy technique. An important consideration is the amount of keratinized tissue present: remember that at least 3 mm in the apicocoronal direction should remain after the surgery is completed.
- Figure (modified flap operation????) 58-4 shows the basic steps in the technique, which can be described as follows: 1. After anesthetizing the area, sounding of the underlying alveolar bone is performed with a periodontal probe to determine the presence and extent of osseous defects. 2. With a no. 15 Bard-Parker blade, the initial scalloped internal bevel incision is made at least 3 mm coronal to the mucogingival junction and includes the creation of new interdental papillae. 3. The same blade is used to thin the gingival tissues in a buccolingual direction to the mucogingival junction. At this point, the blade establishes contact with the alveolar bone, and a fullthickness or split-thickness flap is elevated. 4. With the use of an Orban knife, the base of each papilla that connects the facial and the lingual incisions is incised. 5. The excised marginal and interdental tissues are removed with curettes. 6. Tissue tabs are removed, the roots are thoroughly scaled and planed, and the bone is recontoured as needed. 7. The flap is replaced and, if necessary, trimmed to reach the bone–tooth junction exactly. The flap is then sutured with an interrupted or a continuous mattress technique, and the area is covered with a periodontal dressing. Sutures and pack are removed after 1 week, and the patient is instructed to start plaque control methods. Usually it is convenient for the patient to use chlorhexidine oral rinses once or twice daily for 2 to 4 weeks
- Current periodontal surgery must consider the following:1) the conservation of keratinized gingiva; (2) minimal gingivaltissue loss to maintain aesthetics; (3) adequate access to the osseous defects for definitive defect correction; and (4) minimal postsurgical discomfort and bleeding by attempting surgical procedures that will allow for primary closure. The gingivectomy surgical technique has limited use in current surgical therapy because it does not satisfy these considerations for periodontal therapy. The clinician must carefully evaluate each patient to address the proper application of this surgical procedure. The current understanding of disease etiology and therapy limits the use of both techniques, but their place in surgical therapy is essential.