#12 gingivectomy .pdf

Gingivectomy and gingival curettage Dr. Jafar Naghshbandi D.D.S ; M.S American Board of Periodontology Special Thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon  Gingivectomy is the excision of the soft tissue wall of the pocket (It’s objective...

Gingivectomy and gingival curettage Dr. Jafar Naghshbandi D.D.S ; M.S American Board of Periodontology Special Thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon  Gingivectomy is the excision of the soft tissue wall of the pocket (It’s objective is the elimination of pockets). Gingivoplasty is the recontouring of gingiva that has lost its physiologic form rather than elimination of pockets. These two procedures are performed together although they may be considered separately for teaching purposes. PRE-REQUISITES 1.There should be adequate zone of attached gingiva so that excision of part of it will still leave a functionally adequate zone. 2.The underlying alveolar bone must be in normal or nearly normal form. If there is bone loss it should be of horizontal in nature. 3.There should be no infrabony defects or pockets. INDICATIONS 1.Eliminate supra-alveolar pockets and pseudo-pockets. 2.Remove fibrous or edematous enlargements of the gingiva. 3.Transform rolled or blunted margins to physiologic form. 4.Create more esthetic form in cases in which exposure of the anatomic crown has not fully occurred. 5.Create bilateral symmetry (where the gingival margin of one incisor has receded somewhat more than that of the adjacent incisor). 6.Expose additional clinical crown to gain added retention for restorative procedures (access to subgingival areas, etc.). 7.Correct gingival craters. CONTRAINDICATIONS 1.The presence of thick alveolar edges, interdental craters or bizarre crestal bone form. 2.When infrabony pockets are present. 3.If pockets extends to/below the mucogingival junction. 4.Inadequate oral hygiene maintenance by the patients 5.Un-cooperative patients. 6.Medically-compromised patients. 7.Dentinal hypersensitivity before the surgical procedure (requires considerable preparation of the patient mentally and is not exactly a contraindication). TYPES OF GINGIVECTOMY 1.Surgical gingivectomy. 2.Gingivectomy by electrosurgery. 3.Laser gingivectomy. 4.Gingivectomy by chemosurgery. Surgical Gingivectomy Armamentarium: 1.Mouth mirror, probe. 2.Pocket markers, Kirkland and Orban interdental gingivectomy knives. 3.Surgical blade, Bard Parker handle. 4.Surgical curettes, Gracey curettes, tissue forceps , scissors. 5.Periodontal dressing. Surgical Procedure Step 1: The pockets on each surface are explored with a periodontal probe and marked with the pocket marker. Step 2: Periodontal-knives are used for incisions on the facial and lingual surfaces as auxiliary instruments, Bard Parker blades No. 11 and 12 and scissors are then used. Discontinuous or continuous incisions may be used. The incision should be beveled at approximately 45 degrees to the tooth surface. Step 3: Remove the excised pocket wall. Clean the area and closely examine the root surface for any deposits. Step 4: Carefully curette out the granulation tissue and remove any calculus and necrotic cementum so as to leave a clean and smooth root surface. Step 5: Cover the area with surgical pack. Procedure for Gingivoplasty Instruments used are periodontal-knife, scalpel, diamond stones or electrodes. a. Tapering the gingival margins. b. Scalloped marginal outline. c. Thinning of the attached gingiva and creating vertical interdental grooves. d. Shaping the interdental papillae to provide sluice ways for the passage of food. Healing after Surgical Gingivectomy Basically healing is by secondary intention: a. The initial response  formation of clot. b. The clot is then replaced by  granulation tissue. c. Within 24 hours  increase in new CT cells mainly angioblasts and by third day numerous fibroblasts are located in this area. d. Capillaries with in two weeks connect with gingival vessels. Surface epithelialization is generally complete after 5 to 14 days. Initially, keratinization is less than what it was prior to surgery. Complete epithelialization takes about 1 month. Gingivectomy by Electrosurgery Advantages: Permits adequate contouring of the tissues and controls hemorrhage. Disadvantages: 1.Patients with poorly shielded cardiac pacemaker. 2.Causes unpleasant odor. 3.If it touches the bone irreparable damage may result. 4.Heat generated by this may cause tissue damage and areas of cemental necrosis. Indications 1.Removal of gingival enlargements. 2.Gingivoplasty. 3.Relocation of frenum and muscle attachments. 4.Incision of periodontal abscesses and pericoronal abscess. Healing after Electrosurgery Some investigators report no significant differences, but others however have reported delayed healing, greater reduction in gingival height and more bone injury after electro surgery. Laser Gingivectomy Most commonly used lasers are carbon dioxide and Nd:YAG lasers: They are used for excision of gingival overgrowth. Their use in periodontal surgery is not supported by research. Gingivectomy by Chemosurgery Chemicals used are 5 percent Para formaldehyde or potassium hydroxide to remove gingiva. Disadvantage: 1. Their depth of action cannot be controlled hence it may also injure normal tissues. 2. Gingival remodeling is not possible. 3. Healing is delayed. Gingival curettage DEFINITION The term curettage is used in periodontics to mean the scraping of gingival wall of a periodontal pocket to separate diseased soft tissue. Whereas scaling refers to removal of deposits from tooth/root surface and root planing means smoothening the root to remove infected and necrotic tooth surface.  TYPES I. Gingival curettage: Consists of removal of inflamed soft tissue lateral to pocket wall. a. Subgingival curettage: It is a procedure that is performed apical to epithelial attachment. b. Inadvertent curettage: Curettage that is done unintentionally during scaling and root planing. II. Surgical curettage Chemical curettage Subgingival curettage Ultrasonic curettage RATIONALE The main accomplishment of curettage is the removal of chronically-inflamed granulation tissue that forms in the lateral wall of the periodontal pocket. This tissue apart from having its usual components like fibroblastic and angioblastic proliferations, also contains areas of chronic inflammation, pieces of dislodged calculus and bacterial colonies. (Justification to curettage is more so from the fact that this granulation tissue which is lined by epithelium may hamper or act as a barrier for the attachment of new fibers).  is it justified to do curettage , just to eliminate the inflamed granulation tissue? when the root is thoroughly planed, the major source of bacteria disappears and the pathologic changes in the periodontal pocket disappears without any need for curettage. Due to this existing granulation tissue also disappears, if any bacteria is present, is destroyed by defense mechanism due to their less number. curettage may also eliminate all or most of epithelium that lines the pocket wall & underlying JE, though there are differing opinions regarding this, the purpose of curettage is still valid particularly in presurgical phase where there is persistant gingival inflammation even after repeated scaling and root planning. Indications 1.As a part of new attachment in moderately deep infrabony pockets located in accessible areas where a type of “closed surgery” is advised. 2.As a non-definite procedure to reduce inflammation prior to pocket elimination procedures like flap surgeries. 3.In patients where extensive surgical procedures are contraindicated like aging, systemic complications, etc. where the treatment is compromised, and prognosis is impaired. 4.Curettage is frequently performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket depth, particularly where pocket reduction surgery has previously been performed.  Basic technique. Other techniques. Curettage as such does not eliminate local factors like plaque and calculus, therefore it should always be followed by scaling and root planing procedures. Basic Technique After adequate local anesthesia, the correct curette is selected and adapted in such a way that the cutting edge is against the tissues. The instrument is inserted so as to engage the inner lining of the pocket wall and is carried along the soft tissue wall usually in a horizontal stroke. The pocket wall may be supported by gentle finger pressure on external surface. In subgingival curettage, the tissue attached between the bottom of pocket and the alveolar crest is removed with a scooping motion of the curette to the tooth surface. The area is flushed to remove debris. If necessary sometimes sutures and a pack may be indicated.  Other Techniques ENAP (Excisional New Attachment Procedure) It is a definitive subgingival curettage procedure performed with a knife. Steps: 1. Adequate local anesthesia, 2. Internal bevel incision is made from margin of free gingiva apically below the base of pocket, it is carried all around the tooth surface, attempting to retain as much interdental tissue as possible. 3. The excised tissue is removed with a curette 4. Root surface is planed to a smooth hard consistency. 5. Approximate wound edges if necessary and place sutures 6. Periodontal dressing.  Ultrasonic Curettage Ultrasonic scalers are used for ultrasonic curettage. The ultrasonic vibrations disrupt tissue continuity, and the epithelium is lifted off. It also alters the morphologic features of fibroblast nuclei. This method has proved to be as effective as the manual method but results in decreased inflammation and less removal of connective tissue. Caustic Drugs Drugs such as sodium sulfide, Antiformin and phenol have been used to induce chemical curettage of the lateral wall of the pocket. Disadvantage is the extent of tissue destruction with these drugs cannot be controlled. Laser Curettage HEALING AFTER SCALING AND CURETTAGE Immediately after curettage, a blood clot fills the pocket area Hemorrhage is also present in tissues with dilated capillaries and increase in polymorphonuclear leukocytes appear on wound surface. Rapid proliferation of granulation tissue occurs shortly after with a decrease in the number of blood vessel. Restoration and epithelialization of sulcus takes place in 2 to 7 days. CLINICAL APPEARANCE AFTER SCALING AND CURETTAGE Immediately: after curettage, the gingiva appears hemorrhagic and bright-red. After one week: the gingiva appears reduced in height with apical shift. The redness is slightly reduced. After two weeks: with proper oral hygiene the gingiva comes back to normal. KEY POINTS TO NOTE 1.Curettage is the scraping of the gingival wall of a periodontal pocket to separate the diseased soft tissue. 2.There are gingival, subgingival and inadvertent curettage which should be differentiated. 3.Indications for curettage are very limited and can be used after scaling and root planing. 4.Curettage can also be performed with the help of chemicals and ultrasonic scalers. The measure of a man's greatness is not the number of servants he has, but the number of people he serves John Hagee