3. INTRODUCTION
Periodontal pocket surgery limited to the gingival tissues only and not
involving underlying osseous structure
Gingival curettage
Gingivectomy
Gingivoplasty
4. Bacterial plaque causes the formation of periodontal pockets and resorption of
alveolar bone due to apical migration of junctional epithelium
6. GINGIVAL CURETTAGE
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
Process by which biofilm and calculus are
removed from supragingival and subgingival
tooth surface
Root planning
Smoothening the root to remove infected
and necrotic tooth surface
Subgingival curettage
Performed apical to the epithelial attachment , severing
the connective tissue attachment to the osseous crest
Inadvertent curettage
Some degree of curettage done unintentionally during
scaling and root planing
7.
8. RATIONALE
Removes granulation tissue
Within which we find : Areas of inflammation
Bacteria , calculus
Epithelial tissue lines granulation tissue : May pose barrier to new fibre attachment
However ,
Granulation tissue slowly resorbs following debridement.
Bacteria eliminated
Tissue heals
Questionable , whether curettage significantly improves health of tissue beyond what
is seen with periodontal debridement .
9. INDICATIONS
Very limited
They can be used after SRP following purposes :
In patients whom extensive surgery is contraindicated owing to systemic disease or
psychologic problems.
Shallow pocket depths with an adequate width and thickness of gingival tissue.
It can be performed as a part of new attachment attempts in moderately deep infra
bony pockets located in accessible areas .
Can be performed on recall visits as a method of maintenance treatment for areas of
recurrent inflammation
In supra bony pockets which do not extend beyond the mucogingival junction
10. CONTRAINDICATIONS
Presence of acute infections such as necrotizing ulcerative gingivitis ( NUG )
Fibrous enlargement of gingiva such as phenytoin hyperplasia
Extension of the base of the pocket apical to the mucogingival junction
If the patient is medically compromised ,
Deep pockets greater than or equal to 5mm
Furcation involvement
11. PROCEDURE
BASIC TECHNIQUE
Curettage does not eliminate the cause of inflammation ( i.e bacterial
plaque and deposits ) . Therefore curettage should always be preceded
by scaling and root planning.
Use of local anaesthesia for scaling and root planning is optional , but it
is always required in case of gingival curettage .
Curette is selected so that cutting edge is against the tissue
Gracey curette or columbia universal curette
Instrument inserted to engage the inner lining of pocket wall , carried
along the soft tissue , in a horizontal way usually
Curette is placed under the most apical edge of the junctional
epithelium to undermine it
Gingival curettage
performed with a
horizontal stroke of the
curette
12. During subgingival curettage ,
Tissues between bottom of pocket and
alveolar crest is removed with a scooping
motion of curette to tooth surface
Area is flushed to remove debris
Tissue is partly adapted to tooth surface
by gentle finger pressure
In some case , suturing of separated
papillae and application of periodontal
pack may be indicated .
13. OTHER TECHNIQUE
1 . EXCISIONAL NEW ATTACHMENT PROCEDURE (
ENAP )
Definitive subgingival curettage procedure that is performed with a knife
In past it is known as mini flap , but it is not an flap procedure .
INDICATIONS
Supra bony pockets
When aesthetics is not important
Slight bone loss with mild – moderate
pocketing ( 3-5 mm )
CONTRAINDICATIONS
Pocket exceed mucogingival junction
Edematous tissue
Furcation involvement
14. TECHNIQUE
Scaling and root planning should be performed at least
one week before the ENAP.
Use bard parker #11 0r #12 blade for incision
Scale and root plane
Coapt tissue back to the teeth with interrupted
interproximal sutures
Hold flap with saline –soaked gauze using light pressure
for 3mins
Place protective dressing
Remove dressing and suture in 7 days
Use cotton applicator stick soaked with 1 – 2 % hydrogen
peroxide to clean the area
If patient is sensitive , replace the dressing for one more
week
Use of chlorhexidine mouth rinse twice daily for 2 weeks
Polish the teeth once dressing is removed
15. 2 . ULTRASONIC CURETTAGE
When applied to the gingiva of experimental animals , ultrasonic vibrations disrupt
tissue continuity , lift off epithelium , dismember collagen bundles and alters
morphological feature of fibroblast nuclei .
Effective for debridement epithelial lining of periodontal pockets
Morse scaler – shaped and rod shaped ultrasonic instruments are used
As effective as manual instruments , but results in less inflammation and less
removal of underlying connective tissue .
16. 3 . CAUSTIC DRUG
This includes : Sodium sulphide
Alkaline sodium hypochlorite solution ( Anti formin )
Phenol
These were used in the past and were by and large ineffective besides causing
untoward damage to the tissues .
They are outdated and have no place in current periodontal practice .
17. HEALING AFTER SCALING AND CURETTAGE
• Immediately , after curettage , blood clot fills the pocket area
• Hemorrhage is also present in tissues with dilated capillaries and abundant PMN’s
appear shortly n wound surface
• Restoration of sulcus requires 2 – 7 days
• Immature collagen fibres appear within 21 days
• Tears in epithelium are repaired
• Healing results in the formation of long JE with no connective tissue in humans .
• In some cases , this long epithelium may be interrupted by “windows” of connective
tissue attachment .
18. CLINICAL APPEARANCE AFTER SCALING
AND CURETTAGE
• Immediately after scaling and curettage , the gingiva appears hemorrhagic 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 .
20. GINGIVECTOMY
• Gingivectomy – excision of the gingiva
Removal of
pocket wall
Visibility &
accessibility
for complete
calculus
removal
Proper
smoothening
of roots
Favourable
environment
for gingival
healing
Restoration of
physiologic
gingival
contour
21. 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 abscess
CONTRAINDICATION
• Need for osseous surgery or examination of the shape and morphology of bone
• When base of pocket is apical to mucogingival junction
• Aesthetic consideration
22. SURGICAL GINGIVECTOMY
A . B . Preoperative
facial and palatal views
C . Marking of depth of
suprabony pocket
D . Bottom of the pockets
are indicated by pin
point markings
E . Beveled palatal
incision with orban knife
F . Facial beveled
incision with a BP no 15
blade extends apical to
perforations made by
pocket marker
Beveled incision can also
be made by Kirkland
knife
G . Interdental incision
and excision of pocket
wall with BP no 12
blade
H . Completed
gingivectomy
I . Surgical site covered
with periodontal
dressing
J . One week after
healing
K . L . Results 22
months after the
operation
23. HEALING AFTER GINGIVECTOMY
The initial response after gingivectomy is the formation of protective clot .
• 2 days : Clot formed . There is proliferation of connective tissue which covers the bone .
Numerous leukocytes and fibrin are present . The polymorphonuclear leukocytes are
called as the “ poly band “
• 4 days : The portion that underlies the clot is replaced by granulation tissue . The
epithelium is seen proliferating but without rete pegs . They extend over part of the
surface . There is dense inflammatory cells infiltration .
• 6 days : Entire wound will be covered by fairly well differentiated stratified squamous
epithelium . There is collagen formation . Inflammatory cells are still present .
• 16 days : The epithelium appears mature with newly formed rete pegs . The connective
tissue is made up of collagen . There is chronic inflammatory exudate present .
• 21 days : Epithelial rete pegs well developed . There is slight hyperplasia of the
epithelium along with spongiosa . There is increase in collagen deposition in connective
tissue . Gingiva is clinically normal .
24. GINGIVOPLASTY
• Gingivoplasty is similar to gingivectomy , but its objective is different .
• Gingivoplasty is the reshaping of gingiva to create physiologic gingival
contours with the sole purpose of recontouring the gingiva in the
absence of pockets
Used to correct deformities like
• Gingival clefts & craters
• Shelf like interdental papilla – ANUG
• Gingival enlargements
27. • Electrosurgery is defined as the intentional passage of high – frequency waveforms or currents
, through the tissues of the body to achieve a controllable surgical effect .
ADVANTAGES
• Control of haemorrhage
• Adequate contouring of the tissue
DISADVANTAGE
• Cant be used in patients with poorly shielded
cardiac pacemakers
• Treatment causes unpleasant odour
• If electro surgery point touches the bone , irreparable damage can be done .
INDICATION
• Superficial procedures like,
Gingival enlargements
Gingivoplasty
Relocation of muscle and frenum
Incision of periodontal abscess and
pericoronal flaps .
28. TECHNIQUE
• Removal of gingival enlargements & gingivoplasty is performed with the
needle electrode . Fully rectified current is used .
Small , ovoid loop or the diamond shaped electrodes are used for festooning
In all shaping procedures , electrode is activated and moved in a concise “
shaving “ motion
• For hemostasis , the ba ll electrode is used . Firstly controlled by direct
pressure then coagulating current is used .
• For acute periodontal abscess drainage with needle electrode without
exerting painful pressure . Followed by regular procedure.
• Frenum and muscles can be relocated using loop electrode
• Acute pericoronitis – bent needle electrode is used for incision .
29. HEALING AFTER ELECTROSURGERY
• Some find there is no difference with healing after electrosurgery and with knives .
• Whereas other find , delayed wound healing , greater reduction in gingival height ,
and more bone injury after electrosurgery .
30. LASER GINGIVECTOMY
• The lasers most often used in dentistry are the carbon dioxide ( CO2 )
and neodymium : yttrium – aluminium – garnet ( Nd:YAG ) qith
wavelength of 10,600 nm and 1064 nm respectively .
• 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 neighbouring tissues and eyes of the
operator .
31. GINGIVECTOMY BY CHEMOSURGERY
• Techniques to remove the gingiva with the use of chemicals such as
5% paraformaldehyde –
Potassium hydroxide
Disadvantage
• Depth of action cant be controlled
• Epithelialization & reformation of JE occurs slowly
• They are not currently used .
32. CONCLUSION
• The gingivectomy surgical technique has limited use in current surgical therapy ,
because it does not satisfy certain criteria like conservation of keratinized gingiva ,
aesthetics , minimal bleeding and discomfort . And also the underlying bone cannot
be visualized , thus flap surgery is preferred .
33. REFERENCE
• CARRANZA’S CLINICAL PERIODONTOLOGY – SECOND SOUTH ASIA
EDITION
• TEXTBOOK OF PERIODONTOLOGY – REVISED SECOND EDITION – RAO
