Periodontal Pocket Reduction Surgery

Periodontal Pocket Reduction Surgery

• Limited to gingival tissues only, not involving underlying osseous structures, without flap surgery
• Two types: Gingival curettage and Gingivectomy

Gingival Curettage

• Scraping of the gingival wall of the periodontal pocket (removal of inner surface of soft tissue wall by a curette)
• Performed apical to epithelial attachment
• Types: Surgical curettage, Chemical curettage, Ultrasonic curettage
• Removes chronically inflamed granulation tissue that forms in the lateral wall of the periodontal pocket
• May be performed with scaling and root planning during the same visit or as a separate operation

Gingival Curettage Procedure

• Local anesthesia by topical or infiltration anesthesia
• Curettage is placed so that the cutting edge is against the tissue
• Inserted to engage the inner lining of the pocket wall and carried along the soft tissue in a horizontal stroke
• Pocket wall may be supported by gently finger pressure on the external surface
• Curette is then placed under the cut edge of the junctional epithelium to undermine it
• In subgingival curettage, tissue attached between the bottom of the pocket and the alveolar crest is removed
• Area is flushed to remove debris and tissue is partly adapted to the tooth by gentle finger pressure

Excisional New Attachment Procedure (ENAP)

• Definitive subgingival curettage procedure performed with a knife or scalpel blade
• Internal bevel incision is made from the margin of free gingiva apically below the base of the pocket
• Excised tissue is removed with a curette and the root surface is planed to a smooth hard consistency
• Approximate wound edges and place sutures and a periodontal dressing if necessary

Ultrasonic Curettage

• Uses ultrasonic scalers to disrupt tissue continuity and lift the epithelium off
• Proved to be as effective as the manual method, results in decreased inflammation and less removal of connective tissue

Chemical Curettage

• Uses drugs such as sodium sulfide, antiformin, and phenol to induce chemical curettage of the lateral wall of the pocket
• Disadvantage: Extent of tissue destruction cannot be controlled

Gingivectomy

• Excision of the gingival
• Provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots
• Removes diseased tissue and local irritants, creating a favorable environment for gingival healing and restoration of physiologic gingival contour

Gingivectomy Healing

• Clot is replaced by granulation tissue
• Epithelial cells migrate from the edge of the wound beneath the clot and cover the wound in 7-14 days
• Keratinize in 2-3 weeks
• Formation of a new epithelial attachment may take as long as 4 weeks

Gingivectomy by Electrosurgery

• Uses high frequency current of 1.5 to 7.5 million cycles per second
• Permits adequate contouring of the tissue and control of hemorrhage
• Contraindications: Use in patients with non-compatible or poorly shielded cardiac pacemaker
• Disadvantages: Unpleasant odor, irreparable damage to bone if electrode touches bone, heat generated can cause tissue damage and loss of periodontal support

Laser Gingivectomy

• Uses carbon dioxide (C02) and neodymium: yttrium-aluminum-garnet (Nd: YAG) lasers
• Beam has been used for the excision of gingival overgrowths, although healing is delayed compared to conventional scalpel gingivectomy
• Precautionary measures are necessary to avoid reflecting the beam on instrument surface, which could result in injury to neighboring tissues or the eyes of the operator