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Gingival surgical procedures
- 1. GINGIVAL SURGICAL PROCEDURES D. OOVIYA
- 2. CONTENTS INTRODUCTION GINGIVALCURETTAGE GINGIVECTOMY GINGIVOPLASTY GINGIVECTOMY BY ELECTROSURGERY LASER GINGIVECTOMY GINGIVECTOMY BY CHEMOSURGERY CONCLUSION REFERENCE
- 3. INTRODUCTION Periodontal pocket surgerylimited to the gingival tissues only and not involving underlying osseous structure Gingival curettage Gingivectomy Gingivoplasty
- 4. Bacterial plaque causesthe formation of periodontal pockets and resorption of alveolar bone due to apical migration of junctional epithelium
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- 6. GINGIVAL CURETTAGE Gingival curettage Theword 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
- 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 canbe 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 acuteinfections 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 doesnot 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 androot 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 . ULTRASONICCURETTAGE 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 . CAUSTICDRUG 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 SCALINGAND 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 AFTERSCALING 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 .
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- 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 ofsuprabony 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 Theinitial 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 issimilar 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
- 25. INSTRUMENTS : • Periodontalknife & scalpel • Rotary coarse diamond stones • Electrodes PROCEDURE • Tapering the gingival margin • Creating scalloped marginal outline • Thinning of attached gingiva • Creating vertical interdental grooves • Shaping interdental papillae
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- 27. • Electrosurgery isdefined 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 ofgingival 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 • Thelasers 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 gingivectomysurgical 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 CLINICALPERIODONTOLOGY – SECOND SOUTH ASIA EDITION • TEXTBOOK OF PERIODONTOLOGY – REVISED SECOND EDITION – RAO
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