A detailed description of various non surgical and surgical procedures in managing periodontal diseases

1. Curettage, Gingivoplasty & Gingivectomy
DR. SAMEER AHMEDDR. SAMEER AHMED
DEPARTMENT OF PERIODONTOLOGYDEPARTMENT OF PERIODONTOLOGY

2. Introduction

3. What is curettage ?
Curettage in periodontics means the scraping of the
gingival wall of a periodontal pocket to separate diseased
soft tissue.
closed, indefinitive surgical procedure
Scaling and root planing may inadvertently
It is performed with sharp curettes in an attempt to remove
(1) the sulcular epithelium & epithelial attachment, &
(2) the inflamed connective tissue of the pocket wall

4. TYPES
Gingival curettage
Subgingival curettage
Inadvertent curettage

5. Aim is to reduce pocket depth by enhancing gingival
shrinkage, new connective tissue attachment, or both.
Aim & Rationale o f Curettage
Rationale
Therefore the need for curettage just
to eliminate the inflamed granulation
tissue appears questionable

6. Removal of granulation tissue
Curettage
Flap surgery - technical rather
than biologic reasons

7. Curettage & Esthetics
Currently, esthetics is a major consideration of therapy
(anterior & requires preservation of the interdental papilla)
When regenerative therapy is not possible, every effort
should be made to minimize shrinkage - avoiding gingival
curettage
Papilla Preservation Technique
Avoid root planing apical to the base of the pocket -
removal of the JE & disruption of CT attachment exposes
non-diseased par of cementum. Root planing in this area
result in excessive shrinkage and recession

8. Indications & Contraindications
Indications
1. Edematous and inflamed tissues
2. Shallow pockets
3. Suprabonypockets
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 microorganisms

9. Contraindications
1. Fibrotic tissue
2. Deep pockets
3. Furcation involvements
4. Treatment of underlying osseous defects

10. Procedure for Curettage
Basic Technique
Does not eliminate the causes of inflammation
(i.e. bacterial plaque and deposits).- preceded by
SRP
Gingival curettage always requires some type of
local anesthesia.
The curette is selected so that the cutting edge will
be against the tissue (e.g., the Gracey No. 13-14 is
used for mesial surfaces and the Gracey No. 11-12
for distal surfaces).4R-4L Columbia Universal
curette
Engage the inner lining of the pocket wall -
horizontal stroke
Pocket wall - supported by gentle finger pressure
on the external surface.

11. In subgingival curettage, the tissues attached between the
bottom of
pocket and alveolar crests are removed with a scooping
motion of
curette to the tooth surface
The area is flushed to remove debris, and the tissue is partly
adapted to the tooth by gentle finger pressure.
Sometimes suturing of separated papillae and application of a
periodontal pack may be indicated.

12. Other Techniques
1) Excisional new attachment procedure (ENAP)
2) Ultrasonic curettage
3)Chemical curettage
4 ) Laser curettage

13. ENAP
Indications
1. Suprabony pockets
2. Adequate keratinized tissue
3. When esthetics are unimportant
4. Gingival enlargement
Advantages
1. Improved root visualization
2. Complete removal of sulcular epithelium & epithelial
attachment
3. Minimal gingival trauma
4. No loss of keratinized gingiva

14. ENAP
Disadvantages
1. Difficult to determine apical extent of epithelial
attachment
2. Does not result in new attachment
Contraindications
1. Pockets exceed Mucogingival junction
2. Edematous tissue
3. Lack of keratinized tissue
4. Osseous defects have to be treated
5. Hyper plastic tissue
6. Close root proximity
7. Furcation involvement

15. Technique – ENAP
Internal bevel incision
Remove the excised tissue with a
curette, & RP…preserve the ct
Approximate the wound
edges

19. Modified E.N.A.P. Technique
In 1977, Fredi and Rosenfeld modified the technique……
partial-thickness, inverse beveled incision down to the
crest of the bone to completely remove tissue about the
periodontal ligament
The flaps were then sutured at the presurgical height
The technique is basically the same in all other aspects.

20. Ultrasonic Curettage.
Ultrasonic vibrations disrupt tissue continuity, lift off epithelium,
dismember collagen bundles, & alter the morphologic features of
fibroblast nuclei.
debriding the epithelial lining of pdl pockets – results in narrow
band of necrotic tissue (microcauterization), which strips off the
inner lining of the pocket.
The Morse scaler-shaped and rod-shaped ultrasonic instruments
used
Ultrasonic instruments to be as effective as manual instruments
……less inflammation and less removal of underlying CT

21. CHEMICAL CURETTAGE
Drugs such as sodium sulfide, alkaline sodium
hypochlorite solution (Antiformin), & phenol have been
proposed & then discarded after studies showed their
ineffectivenes.
The extent of tissue destruction …..cannot be controlled,
may increase rather than reduce the amount of tissue to be
removed by enzymes and phagocytes.

22. Laser curettage

23. Laser curettage
The goals …are epithelial removal, as with previous methods
& in addition, bacterial reduction.
A short-term study reported that Nd:YAG laser treatment did
not produce statistically significant bacterial reduction

24. Laser ENAP
A recent commercial advertisement describes a "revolutionary . .
breakthrough in periodontal surgery that regenerates new attachment"
through the application of "a Laser ENAP procedure."
Despite FDA approval for sulcular debridement, the use of lasers for ENAP
and gingival curettage as proposed in the advertisement and several recent
journal articles should be evaluated in light of the available evidence.

25. HEALING AFTER SCALING AND 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.

26. CLINICAL APPEARANCE AFTER CURETTAGE
Immediately after curettage, the 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

27. The American Academy of Periodontology Statement
Regarding Gingival Curettage
The actual result ……..long JE, which is the same result with
SRP alone.
The theoretical clinical advantage of curettage over SRP
alone was eliminated when new CT attachment was shown
--unattainable goal.
Short- and long-term clinical trials have confirmed that
gingival curettage provides no additional benefit when
compared to SRP alone in terms
of PD reduction, attachment gain, or inflammation reduction.

28. Gingivectomy and Gingivoplasty

29. Introduction
What happens if your teeth look too small,
too wide, too short or are not symmetrical
in size?
Do you have a "gummy smile"?

30. Definition
Gingivectomy is the Excisional removal of gingival tissue
for pocket reduction or elimination.
Gingivoplasty is the reshaping of the gingiva to attain a
more physiologic contour
Gingivectomy and gingivoplasty are usually
performed at the same time

31. Rationale
1. Pocket elimination for root accessibility
2. Establish physiologic gingival contours
Indications
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. Unaesthetic or asymmetrical gingival topography
8. For exposure of soft-tissue impaction to enhance eruption
9. To facilitate restorative dentistry

32. Contraindications
1. An inadequate zone of keratinized tissue
2. Pockets that extend beyond the Mucogingival line
3. The need for osseous resection or inductive techniques
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

33. Advantages
1. Predictability
2. Simplicity
3. Ease of pocket elimination
4. Good access
5. Favorable esthetic results
Disadvantages
1. Healing by secondary intention
2. Bleeding postoperatively
3. Loss of keratinized gingiva
4. Inability to treat underlying osseous deformities

34. Gingivectomy Technique

35. Presurgical Phase
Reduce gross inflammation & remove local factors (calculus,
plaque, or overhanging restorations).
After initial healing, zone of attached tissue can be assessed
properly.
Adequate local anesthesia is given. ….. vasoconstrictor.
Pockets are probed ..check depth and make sure they do not
extend beyond the Mucogingival junction
By sounding, the osseous topography is determined and the need
for osseous surgery determined

36. Pocket Marking

37. Incisions
Continuous or Discontinuous
Scalpel or GV knife
Bevel of 45

38. SURGIAL GINGIVECTOMY

40. Gingivectomy Incision

41. Gingivoplasty
Purpose is different.
Gingivectomy is performed to eliminate periodontal pockets
and includes reshaping as part of the technique.
Gingivoplasty is a reshaping of the gingiva to create physiologic
gingival contours, with the sole purpose of recontouring the
gingiva in the absence of pockets.
Gingivoplasty may be done with a periodontal knife, a scalpel,
rotary coarse diamond stones, or electrodes.

42. Healing after Surgical Gingivectomy
Clot - granulation tissue.
By 24 hours, there is an increase in new connective tissue
The highly vascular granulation tissue grows coronally, creating
a new free gingival margin and sulcus. Capillaries ..and within 2
weeks the connect with gingival vessels .
After 12 to 24 hours, epithelial cells at the margins of the wound
start to migrate over the granulation tissue
Epithelial activity at the margins reaches a peak in 24 to 36
hours.The epithelial cells advance by a tumbling action, with the
cells becoming fixed to the substrate by hemidesmosomes and a
new basement lamina
Surface epithelization is generally complete after 5 to 14 days.

43. During first 4 weeks after gingivectomy, keratinization is less
than it was prior to surgery.
Complete epithelial repair takes about 1 month. Vasodilation
and vascularity begin to decrease
Complete repair of the connective tissue takes about 7 weeks.
gingival fluid in humans is initially increased after gingivectomy
&
diminishes as healing progresses. Maximal flow is reached after
1 week
Postgingivectomy healing are the same in all individuals, the time
required for complete healing varies depending on the area
of the cut surface and interference from local irritation and infection.

44. Gingivectomy by Electrosurgery
Advantages
Electrosurgery permits an adequate contouring of the tissue
and controls hemorrhage
Disadvantages
Noncompatible or poorly shielded cardiac pacemakers.
Unpleasant odor.
If the electrosurgery point touches the bone, irreparable damage
can be done
Cementum burn.

45. Therefore the use o f electrosurgery should be limited to
superficial procedures such as removal of gingival
enlargements, gingivoplasty, relocation of frenum and muscle
attachments;
extreme care should be exercised to avoid contacting the tooth
surface.
It should not be used for procedures that involve proximity to
the bone such as flap operations, or mucogingival surgery.

46. Technique
The removal of gingival enlargements and
gingivoplasty is performed with the needle
electrode, supplemented by the small ovoid loop
or the diamond-shaped electrodes for festooning.
A blended cutting and coagulating (fully rectified)
current is used.
In all reshaping procedures, the electrode is
activated and moved in a concise "shaving"
motion.
For hemostasis, the ball electrode is used.
Electrosurgery is helpful for the control of isolated

47. Healing after Electrosurgery
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.
There appears to be little difference in the results obtained after
shallow gingival resection with electrosurgery and that with
periodontal knives. However, when used for deep resections
close to bone, electrosurgery can produce gingival recession,
bone necrosis and sequestration, loss o f bone height,
furcation exposure, and tooth mobility, which do not occur
with the use of periodontal knives

48. Laser Gingivectomy

49. Laser Gingivectomy
The lasers most commonly are (CO2) and (Nd:YAG), which have
wavelengths of 10,600 nm &1064 nm, respectively, both in the
infrared range
The CO2 laser beam has been used for the excision of gingival
growths, although healing is delayed when compared with healing
after conventional scalpel gingivectomy.
The use of laser beam for oral surgery requires precautionary
measures to avoid reflecting the beam on instrument surfaces, which
could result in injury to neighboring tissues and the eyes of the

50. Gingivectomy by Chemosurgery
5% paraformaldehyde or potassium hydroxide
They are presented here to provide a historical perspective.
Disadvantages:
1. The depth of action cannot be controlled
2. Gingival remodeling cannot be accomplished effectively.
3. Epithelialization and reformation of the junctional epithelium
and reestablishment of the alveolar crest fiber system are slower
in chemically treated gingival wounds than in those produced by
a scalpel.
The use of chemical methods therefore is not recommended.