This document provides an overview of different gingival surgical techniques including gingival curettage, gingivectomy, and gingivoplasty. It discusses the history, rationale, indications, contraindications, procedures, healing processes, and clinical appearances for each technique. Gingival curettage involves scraping the gingival pocket wall to remove diseased soft tissue, while gingivectomy is the excision of gingiva to eliminate supra bony pockets. Different techniques for performing these surgeries include using curettes, electrosurgery, lasers, or chemosurgery. Proper application of these techniques aims to reduce inflammation and promote new tissue attachment and bone regeneration.

1. GINGIVAL SURGICAL TECHNIQUES
Presented to: Presented by:
Dr.Amit Goel Supriya Bhat
Dr.Shiva Chauhan Roll No.53
Dr.Malvika Thakur BDS 4TH YEAR

2. CONTENTS
 Introduction
 History
 Gingival curettage
 Rationale for curettage
 Indications & contraindications
 Procedure
 Other techniques
 Healing after curettage
 Clinical appearance after curettage
 Gingivectomy
 Indication & contraindications
 Various techniques
 Healing after gingivectomy
 Gingivoplasty
 Conclusion
 References

3. INTRODUCTION
Bacterial Plaque
causes the
formation of
Periodontal
Pockets and
resorption of
alveolar bone due
to apical migration
of Junctional
Epithelium.
Limited to gingiva and
not involving underlying
osseous structures
Gingival curettage
Gingivectomy
Gingivoplasty
Current understanding of
disease etiology and
therapy limits the use of
both techniques, but their
place in surgical therapy is
essential.

4. TREATMENT OF PERIODONTAL POCKETS
Pocket
reduction Pocket
elimination

5. PERIODONTAL POCKET
MANAGEMENT
SUPRA/SUBGINGIVAL
DEBRIDEMENT
ORAL HYGIENE
INSTRUCTIONS
RE-EVALUATION
POCKET
ELIMINATION
POCKET
REDUCTION
SUPPORTIVE
PERIODONTAL CARE
•GINGIVECTOM
Y
•APICALLY
REPOSITIONE
D FLAP
•ACCESS
FLAP
•MODIFIED
WIDMAN
•ENAP

6. HISTORY
 John W Riggs (1811-1885)- In an 1876 paper,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.
 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.

7. WHAT IS CURETTAGE?
 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)
 Curettage is a closed, definitive surgical procedure performed
under local anesthesia and aimed at pocket reduction,
elimination, reattachment, or new attachment.
 It is performed with sharp curettes in an attempt to remove:
(1) The sulcular epithelium and the epithelial attachment
(2) The inflammed connective issue of the pocket wall

8. TERMINOLOGIES
 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.
Extent of gingival
curettage
Subgingival
curettage

9. RATIONALE
 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

10. According to Academy report in 2002, short and long term clinical trails
have confirmed that gingival curettage provides no additional benefits
when compared to SRP alone.
After comparing SRP alone to curettage plus SRP, it was concluded that
curettage “did not serve any additional useful purposes”.
Additionally, the American Academy of Periodontology did not include
gingival curettage as a method of treatment in its guidelines for
periodontal therapy. J periodontol,2002

11. INDICATIONS CONTRAINDICATIONS
1) Edematous and inflammed
tissues
2) Shallow pockets
3) Suprabony pockets
4) As part of initial preparation
prior to open surgical
procedures in an attempt to
achieve tissue quality that
can be handled easily
5) Progressive attachment or
alveolar bone loss
6) Increased levels of
pathogenic microorganism
1) Fibrotic tissue
2) Deep pockets ≥ 5mm
3) Furcation involvements
4) Medically compromised
patient

12. Basic Technique with a Curette
Instruments:
 Gracey curettes
 Universal curettes
 Isolation & Anesthetize :
 Local infiltration is given to anesthetize the isolated selected
site.
 Insertion of Curettage
 Sharp Gracey(Gracey #13-14 for mesial surfaces,Gracey #11-12
for distal surfaces) or Universal curette(4R-4L) is inserted with the
cutting edge against the tissue so as to engage the inner lining of
pocket wall & junctional epithelium.

13. Curette the soft tissue wall :
 Curette is carried along the soft
tissue in a horizontal stroke
The pocket wall is supported by
gentle finger pressure on the
external surface.
 Several overlapping strokes are
used to completely remove the
epithelium & underlying
granulation tissue.
Gingival curettage performed with a
horizontal stroke.
In subgingival curettage,
the tissue attached to the
bottom of the pocket &
alveolar crest are removed
with a scooping motion of
the curette to the tooth
surface.
A-elimination of pocket lining
B-elimination of junctional epithelium
C-procedure completed

14. Other Techniques
Other techniques for gingival curettage include
1. The excisional new attachment procedure(ENAP)
2. Ultrasonic curettage,
3. The use of caustic drugs.
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.
ENAP
Gain new attachment
Decrease probing depth
Access root surface

15.  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.
 Remove the excised tissue with a
curette and perform root planing on all
exposed cementum to achieve a
smooth hard surface.
 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

16. ENAP Modification
In 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.
Initial incision made to
crest of pocket
Inner wall remove to
crest of bone&pdl
Healed tissue

17. ULTRASONIC CURETTAGE
 Ultrasound is effective for debriding the epithelial lining of
periodontal pockets. 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 instruments
are used for this purpose.
 Nadler H-1962 found ultrasonic instruments to be as effective
as manual instruments for curettage but resulted in less
inflammation and less removal of underlying connective tissue.

18. CAUSATIVE AGENTS
 The use of caustic drugs has been recommended to induce a
chemical curettage of the lateral wall of the pocket or even the
selective elimination of the epithelium.
 Drugs such as sodium sulfide, alkaline sodium hypochlorite
solution (Antiformin)and phenol, have been proposed and then
discarded after studies indicated 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.

19. Healing after curettage
Immediately after curettage - a blood clot
Hemorrhage-polymorphonuclear
leukocytes appear shortly
Rapid proliferation of granulation tissue
Restoration and epithelialization of the
sulcus require 2 to 7 days
Restoration of the JE - 5 days after
treatment
Immature collagen fibers - 21 days.

20. Immediately
after
curettage-
gingiva
appears
hemorrhagic
and bright
red.
After 1 week- the
gingiva appears
reduced in height-
apical shift in the
position of the
gingival margin.
The gingiva is also
slightly redder than
normal
After 2 weeks -
normal color,
consistency,
surface texture,
and contour of the
gingiva are
attained and
gingiva margin is
well adapted to the
tooth.
Clinical Appearance After Scaling And
Curettage

21. DURATI-
ON
CONNECTIVE
TISSUE CHANGES
EPITHELIAL CHANGES CLINICAL CHANGES
Immediat
ely
• Hemorrhage
• a/c inflammatory
reaction
• Removal of ep. lining
• Few cells may remain
• Blood & exudate
1st day • Marked
inflammation
• Epithelial migration
begins (0.5-1mm/day)
• Edematous
• Discoloration persists
2nd day • Inflammation 
• Vascularity 
• Epithelium begins to
cover the gingival corium
•Discoloration 
• Edema still present
4th-6th
day
• Chr inflammation
• Collagenation
• Matrix formation
• Restoration of junctional
& sulcular epithelium -
7th-10th
day
•  Collagen
formation&
organisation
• Epithelium formation is
complete
• Edema 
• Rigid & well adapted gingival
wall
10th-14th
day
• Repair of C.T
•  vascularity
• Surface keratinization  • Normal color
• Stippling appears
• Gingival shrinkage
After 2
weeks
• Mature collagen
• New sub sulcular
& marginal vessels
-
• Color, contour, consistency,
texture.
• Well adapted marginal gingiva

22. GINGIVECTOMY
GINGIVECTOMY means EXCISION OF THE GINGIVA.
Removal
of pocket
wall
Visibility
&
accessibil
ity for
complete
calculus
removal
Proper
smoothen
ing of
roots
Favourabl
e
environm
ent for
gingival
healing
Restorati
on of
physiologi
c gingival
contour

23. INDICATIONS CONTRAINDICATIONS
1) Elimination of suprabony
pockets.
2) Elimination of gingival
enlargement .
3) Elimination of suprabony
periodontal abscess.
4) The presence of furcation
involvement (without
associated bone defects)
where there is wide zone
of attached gingiva.
5) Pericoronal flap
1) The need for bone
surgery or examination of
the bone shape and
morphology.
2) Situations in which the
bottom of the pocket is
apical to the
mucogingival junction.
3) Esthetic considerations,
particularly in the anterior
maxilla

24. Various techniques of gingivectomy
Surgical gingivectomy
Gingivectomy by
electrosurgery
Laser gingivectomy
Gingivectomy with
chemosurgery

25. SURGICAL TECHNIQUES
INSTRUMENTS
 Mouth mirror
 Probe
 Pocket markers
 Kirkland and orban interdental knives
 Surgical blade,bard parker handle
 Surgical curette, gracey curette
 Tissue forceps
 Scissors
 Periodontal dressing

26. Procedure
 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 are used for incisions on the facial
and lingual surfaces and those distal to terminal tooth in the arch.
Bard-parker knives #11 and #12 and scissors are used as
auxiliary instruments.

27.  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

28.  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.

30. HEALING AFTER SURGICAL
GINGIVECTOMY
 Initial response
1. Blood clot formation
2. Underlying tissue is acutely inflamed and necrotic and soon
replaced by the granulation tissue.
 24 hours later
1. Increased connective tissue cells ( mainly angioblasts)
2. Epithelial cells at the margins of the wound start migrating over the
granulation tissue. Epithelial activity reaches a peak in 24 to 36
hours.

31. 3 days later
1. Young fibroblasts are seen
2. Highly vascular granulation tissue grows coronally creating free
gingival margin and sulcus
2 weeks
1. Capillaries from vessels of periodontal ligament migrate into
connective tissue and connect with gingival margins
2. After 5 to 14 days, surface epithelialization is generally complete
3. Complete repair takes about 1 month. – Connective tissue repair in
7 weeks and the pigmentation is diminished .

32. By electrosurgery(surgical diathermy)
Uses high frequency current of 1.5 to 7.5 million cycles per
second.
ADVANTAGES
 Control of hemorrhage
 Adequate contouring of the tissue
DISADVANTAGES
 Cannot be used in patients who have poorly shield
cardiac pacemakers.
 Unpleasant odour
 If the electro surgery point touches the bone irreplacable
damage can be done.
 When electrode touches the root,cementum burn are produced.

33. INSTRUMENTS:
 Needle electrode 0.0075inch – 0.015inch
PROCEDURE:
 Area must be slightly moist
 Blended cutting and coagulating current is used
 Electrode must be in constant motion to prevent heat build-
up .
 Debris should be cleaned with isopropyl alcohol from the
electrode for each motion.

34. INDICATIONS
 Removal of gingival enlargement.
 Gingivoplasty
 Relocation of frenum and muscle attachments.
 Incision of periodontal and pericoronal abscess.
TECHNIQUE
For gingivoplasty: needle electrodes and diamond shaped
electrodes are used for festooning. In all reshaping procedures
electrodes are activated and moved in a concise “shaving”
motion.
For abscess drainage: incision can be made with the needle
electrode.
 For hemostasis: ball electrode is used.
 For relocation and of frenum muscle attachment: loop
electrode is used.

36. LASER GINGIVECTOMY
The laser used in dentistry are the carbon
dioxide and the Nd:YAG which have
wave lengths of 10,600nm and 1064nm.
 Advantages :
 Completely dry, bloodless surgery.
 Surgical time is reduced
 Instant sterlization of the area,
decreasing the chances of bacteremia.
Minimal postoperative pain, swelling
and scarring.
 Disadvantages
 Protective eyewear should be used
 High cost of the equipment.

38. CHEMOSURGICAL GINGIVECTOMY
 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 , re-establishment of the
alveolar crest fiber system areoccursslowly – TonnaE1967
 Not recommended

39. GINGIVECTOMY
BEFORE AFTER

40. 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

41. Procedure
 Tapering the Gingival Margin
 Creating scalloped marginal outline
 Thinning of attached gingiva
 Creating vertical interdental grooves
 Shaping interdental papilla

42.  Current understanding of disease etiology & therapy limits the
use of these techniques, but their place in surgical therapy is
essential.
 Current periodontal surgery must consider the conservation of
keratinized gingiva, minimal gingival tissue loss to maintain
esthetic, adequate access to osseous defects for definitive defect
correction, minimal post operative discomfort and bleeding by
attempting surgical procedures that will allow primary closure.
CONCLUSION

43. REFERENCES
 Carranza’s clinical periodontology: 10th edition
 Essentials of clinical periodontology:3rd edition
Shantipriya Reddy
 Textbook of periodontics, Shalu Bathla
 Lindhe, Karring, Lang: Clinical Periodontology &
Implant Dentistry. Blackwell Munksgaard; 5th Edititon
 The American Academy of Periodontology statement
regarding curettage.J periodontol 2002