Gingival Surgical Techniques Gingivectomy baeW/> aa Dr Ahmed Jarrar BDS, MSc, Pal. Board Perio., Jor. Board Perio. Department of OMFS And PERIODONTOLOGY Faculty of Dentistry Arab American University of JeninHISTORICAL PERSPECTIVE History of gingivectomy can be dated back to 1742, when Fauchard describe the procedure to remove excessive tissue. Robicsek in 1884, later on described the so called gingivectomy procedure as straight incision technique in which the tissues were excised and the granulation tissue eliminated. Pickerill’s book “Stomatology in General Practice”, published in 1912, described the procedure and very reasonably named the operation gingivectomy. Zentler in 1918 gave scalloped incision technique for gingivectomy.* Gingivectomy is thought to be introduced as an official periodontal therapy when the idea of periodontal etiology shifts from bone to soft tissue. This is mainly due to Kronfeld in 1935, who emphasized that periodontal disease is not the disease of the bone. * Gingivectomy was later defined by Grant et al in 1979 as being the excision of the soft tissue wall of a pathologic periodontal pocket.DEFINITION * According to the World Workshop in Periodontics (1989), gingivectomy is defined as “an excision of the soft tissue wall of the periodontal pocket”.OBJECTIVES i. Pocket elimination by gingival resection. ii. Development of physiologic tissue form for disease prevention.INDICATIONS i. Elimination of suprabony pockets. ii. Elimination of gingival enlargement. iii. Elimination of suprabony periodontal abscess. iv. To expose additional clinical crown to gain added retention for restorative purposes and to provide access to subgingival caries. v. The presence of furcation involvement (without associated bone defects) where there is a wide zone of attached gingiva. vi. Pericoronal flap.CONTRAINDICATIONS i. The need for bone surgery or examination of the bone shape and morphology. ii. Situations in which the bottom of the pocket is apical to the mucogingival junction, gingivectomy will excise most of the gingiva and leave an inadequate zone of gingiva. iii. Esthetic considerations, particularly in anterior maxilla. iv. If the patient complains of tooth senstivity before surgery. Although it is relative contraindication, as the cause of any complaint should be treated before the surgery and if the sensitivity cannot be controlled, surgery should be contraindicated.LIMITING CIRCUMSTANCES 1. Palatal aspects of maxillary posterior teeth: When the palatal vault is shallow and the depth of periodontal involvement is near or enters the vault area, gingivectomy on the palatal aspect of maxillary posterior teeth may result in elimination of most if not all of the palatal gingiva, placing the gingival margin at or near a level of coincident with that of the roof of the mouth. 2. Mandibular retromolar lesions: When an incision is made on movable and delicate mucosa, this tissue often cuts poorly, bleeds profusely and may be difficult to resect and shape. The use of the distal wedge procedure, often simplifies the management of retromolar tissue.3. Maxillary tuberosity areas: When soft tissue is so great, relative to the depth of periodontal involvement on the distal aspect of the last molar, that its level resection would bring about surgical entry into the mucosa of the hamular notch. It may be more appropriate to perform a distal wedge procedure to eliminate diseased tissue immediately adjacent to the distal portion of the molar. 4. Cases of emotional stress: With age, diminish patient cooperation and motivation, retarded healing, etc. have a direct bearing upon the desirability of the surgical therapy. Such patient is a poor surgical risk and requires therapeutic modification.DRAWBACKS 1. Tissue wound heals by secondary intention. 2. Alveolar bone defects are not revealed and therefore cannot be treated adequately. 3. Gingivectomy is a radical procedure in which zone of attached gingiva is compromised/may be eliminated. Thus, attached gingiva is wasted. 4. Clinical crown are lengthened considerably and need to be explained to the patient before surgery. 5. It may lead to dentin hypersensitivity due to root exposure.GINGIVOPLASTY Gingivoplasty first described by Goldman in 1950 as a plastic procedure of which the gingival tissue was removed. Sugarman in 1951 describe electrosurgical gingivoplasty in his case report. Gingivoplasty can be defined as recontouring of gingiva that has lost its physiologic form. Gingivoplasty was introduced to facilitate dealing with abnormal form of gingiva and was essentially a surgical procedure designed to reshape gingiva without necessarily reducing sulcular depth.* The purpose of gingivoplasty is different from gingivectomy, as gingivoplasty is just reshaping of gingiva to create physiologic gingival contours, with the sole purpose of recontouring the gingiva in the absence of pockets, while the objective of gingivectomy is to eliminate pocket.* Indications of gingivoplasty: i. Need for correction of the grossly thickened gingival margin. ii. Gingival clefts and craters caused by necrotizing ulcerative gingivitis that interfere with normal food excursion, collect plaque and food debris. iii. Sharply varying levels of gingival margin in adjacent areas. iv. Saucer shaped deformities, buccolingual in the interproximal regions.* Instruments: Gingivoplasty may be done with a periodontal knife, scalpel, rotary coarse diamond stones or electrode. * Steps in the gingivoplasty procedure are similar and resembles those performed in festooning artificial dentures namely: i. Tapering the gingival margin. ii. Creating a scalloped marginal outline. iii. Thinning the attached gingiva. iv. Creating vertical interdental grooves and shaping the interdental papillae to provide embrasures for the passage of food.Scrapping: Use a scalpel as a hoe and pass the instrument tightly but firmly over a firm, tough tissue surface which results in shaving of the surface. The use of rotary abrasives consists essentially of abrading tissue until it has assumed the desired form. The rules governing the application of the rotary abrasive to soft tissue are exactly those that apply to hard tissue. Asteam of water on the instrument expediates the procedure immeasurably just as it does on bone, enamel or dentin. Accelerated speed ensures a smooth, rapid operation while the stream of water provides temperature control and prevents clogging of instruments.TYPES OF GINGIVECTOMY PROCEDURE 1- Surgical Gingivectomy: - Surgical Instruments: ¢ Pocket markers: Goldman-fox, Crane Kaplan (Fig. 1A) © Broad-bladed, round scalpels: Goldman-fox no. 7, Kirkland knife (Fig. 1B) © Interproximal knife: Goldman-fox no. 8, 9 and 10, Orban’s knife (Fig. 1C)A B € Fig. 1: A. Pocket marker. B. Kirkland knife C. Orban’s knife¢ Surgical handle: Bard Parker no.3 or angulated handle (Blake’s handle) with blade no 11,12,15 ¢ Curettes ° Tissue nipper (Fig. 2), and scissors. Fig. 2: Tissue nipper- Procedure: © Mark bleeding points: + AfterLA is given in the selected site, mark bleeding points with the help of pocket marker systematically, beginning on the distal surface of the tooth, then on the facial and mesial surface. * The procedure is repeated on the lingual/palatal surface. * Beak of pocket marker must be parallel to root surface. * Pinpoint perforations individuate pocket depth which is used as a guideline for the incision.© Incisions: * Discontinuous/continuous incision is given apical to the bottom of the bleeding point beginning at the most terminal tooth (Fig. 3). Discontinuous incision Bleeding points EAE Continuous incision 4 Bleeding points Figs .3: Incisions: (A) Discontinuous incision; (B) Continuous incision* Once the primary incision is completed on the buccal and lingual aspect, Orban’s knife or Waerhaug knife is placed at angle of 45° to free the tissue interproximally. at : a ia Extemal bevel incision (in apicocorenal direction) Fig. 4: Mark the depth of pocket with pocket marker and give external bevel incision apical to the // | | Hef | bleeding point making 45° angle to the long axis of tooth i] tr ff° Tissue removed: * The incised tissues are carefully removed with the help of curette or scaler. The remaining tissue tabs are removed with scissors. * The gingival margins should be thin and beveled and if necessary corrected by means of knives or rotating diamond burs. © Scaling and root planing: * The calculus and necrotic cementum on the tooth are removed with the help of scalers and curettes. © Periodontal dressing: * Bleeding is controlled and after that periodontal dressing is applied over the treated site primarily for patient comfort. Thereafter, patient is given postoperative instructions.External bevel incision is given at an angle of 45° apical to the base of the pocket with the help of Kirkland knife or blade no.11 or 15 with BP handle no.3 or angulated Blake’s handle. The blade must pass fully through the tissue to the tooth in coronal direction (Figs .4 and .5). The incision should be as close as possible to the bone without exposing it so as to remove the soft tissue coronal tothe bone. The main principle here is to eliminate pocket all the way to the base without exposing the bone.Figs .5 A and B : (A) Incorrect incisions: 1. Shallow incision (Fail to remove pocket), 2. No bevel incision (Result in bone exposure); (B) Correct incision° Tissue removed: * The incised tissues are carefully removed with the help of curette or scaler. The remaining tissue tabs are removed with scissors. * The gingival margins should be thin and beveled and if necessary corrected by means of knives or rotating diamond burs. © Scaling and root planing: * The calculus and necrotic cementum on the tooth are removed with the help of scalers and curettes. © Periodontal dressing: * Bleeding is controlled and after that periodontal dressing is applied over the treated site primarily for patient comfort. Thereafter, patient is given postoperative instructions.2- Laser Gingivectomy: * The lasers most commonly used for gingivectomy are the CO, having wavelength of 10600 nm and Neodymium:yttrium-Aluminium-garnet (Nd:YAG tr) having wavelength of 1064 nm both in infrared range.+ Advantages: i. Laser offers an almost completely dry, bloodless surgery. ii. Because of dried field, surgical time may be reduced. iii. There is instant sterilization of the area, decreasing the chances of bacteremia. iv. This is noncontact surgery, thus no mechanical trauma to the surgical site, v. There is prompt healing with minimal postoperative swelling and scarring. vi. Postoperative pain appears to be greatly reduced.* Disadvantages: i. There is loss of tactile feedback in using the instrument. ii. It is imperative that all operating room personnel wear safety glasses for protection of their eyes. iii. There is the necessity for hospitalization. iv. High cost of the equipment.3- Gingivectomy by Electrosurgery: Instruments: Needle electrode (thickness varying from 0.0075 inch to 0.015 inch), small ovoid loop/diamond shaped electrodes. Procedure: - The site must not be too dry otherwise excessive sparking will result. Conversely, if excessive moisture is present, considerable surface coagulation will occur instantly. - For the best results, the site should be very slightly moist.+ Advantages: i. It provide clear operating area with little/no bleeding. ii. Lack of pressure to incise tissue, thus allowing a more precise incision than is obtained by a scalpel. iii. Minor tissue loss after healing. iv. Self-sterilization of the tip of the active electrode. v. Scar-free healing by primary intention, when used properly. vi. Greater ease for the patient as well as for the operator.* Disadvantages: It causes an unpleasant odor. If the electrosurgery point touches the bone, irreparable damage can occur. © When electrode touches the root, areas of cementum burns are produced.4- Gingivectomy by Chemosurgery: * Five percent paraformaldehyde or potassium hydroxide were the chemicals used to perform gingivectomy which is no longer in use because of the following disadvantages associated with it: © The depth of chemical action cannot be controlled. © Gingival remodeling cannot be accomplished effectively. ¢ Epithelialization and reformation of the junctional epithelium, re-establishment of the alveolar crest fiber system are slower in chemically treated gingival wounds than in those produced by scalpel.HEALING AFTER GINGIVECTOMY Healing after gingivectomy is by secondary intention. Bernier J and Kaplan H reported the following time sequence for healing following gingivectomy in humans. The initial response after gingivectomy is the formation of a protective surface clot; the underlying tissue becomes acutely inflamed with some necrosis. The outer epithelium heals by approximately 14 days but sulcular epithelium requires 3 to 5 weeks to heal. Twelve hours after gingivectomy there is slight reduction in cementoblasts and some loss of continuity of the osteoblastic layer on the outer aspect of alveolar crest.* New bone formation occurs at the alveolar crest as early as the 4th day after gingivectomy and new cementoid appears after about 10 to 15 days. * Thus, total gingivectomy healing takes place in about 4 to 5 weeks and remodeling of the alveolar bone crest has been shown to occur during this phase. * Gingivoplasty wound often heal faster than gingivectomy wound.* 2nd day + 4th day h * 6th day Clot formation v ¢ Clot replaced by granulation tissue ¢ Epithelium without rete pegs extends over part of the surface © Dense inflammatory infiltration v © Wound is covered by stratified squamous epithelium ¢ Collagen formation starts in the connective tissue v16th day 21st day ¢ Epithelium with rete pegs appear ¢ Dense collagenous connective tissue appears v ¢ Epithelial rete pegs well developed, with thickening of stratum corneum ¢ Increased Collagen formation in the connective tissue ° Gingiva clinically appear normalThe tissue changes that occur in post gingivectomy healing are the same in all individuals, but the time required for complete healing varies, depending upon the local and systemic factors influencing wound healing (interference from local irritation, infection and age). Gingivectomy may be performed be means of scalpels, lasers, electrode or chemicals. In gingivectomy, external bevel incision is given at 45° to the tooth surface in apicocoronal direction. Gingivectomy wound heals by secondary intention.Gingival Surgical Techniques Gingival Curettage ase > aa Dr Ahmed Jarrar BDS, MSc, Pal. Board Perio., Jor. Board Perio. Department of OMFS And PERIODONTOLOGY Faculty of Dentistry Arab American University of JeninINTRODUCTION * Gingival curettage consists of the removal of the inflamed soft tissue lateral to the pocket wall. * Gingival curettage, as originally conceived, was designed to promote new connective tissue attachment to the tooth, by the removal of pocket lining, junctional epithelium and the subjacent granulation tissue. * The actual result obtained with curettage is most often a long junctional epithelium, which is the same result obtained with scaling and root planing alone.* Gingival curettage, although surgical in nature, is a closed procedure. It does not afford the improved root surface access and visibility as gained with flap surgery that is needed to achieve complete mechanical removal of plaque, calculus, and biofilm. * The major disadvantage of this procedure is limited access especially in deep, tortuous and infrabony pockets.TERMINOLOGY ¢ Gingival curettage is a surgical procedure designed to remove the soft tissue lining of the periodontal pocket with a curette, leaving only gingival connective tissue lining. © Inadvertent curettage is the curettage which is done unintentionally when scaling and root planing procedure is performed. ¢ Subgingival curettage refers to the procedure that is performed apical to the epithelial attachment, severing the connective tissue attachment down to the osseous crest.INDICATIONS . 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 intrabony pockets located in accessible areas. . Curettage can be performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation. . In suprabony pockets which do not extend beyond the mucogingival junction.CONTRAINDICATIONS 1. Presence of acute infections such as necrotizing ulcerative gingivitis (NUG). 2. Fibrous enlargement of gingiva such as phenytoin hyperplasia. 3. Extension of the base of the pocket apical to the mucogingival junction. 4. If the patient is medically compromised, the benefits versus the risks of the surgical procedure should be carefully weighed before commiting the patient to the procedure.PROCEDURE - Basic Technique (With Curette): * Instruments: Gracey curettes, Columbia universal curettes. e Isolate and anesthetize: Local infiltration is given to anesthesize the isolated selected site. e Insertion of curette: Sharp Gracey or Columbia Universal curette is inserted with cutting edge against the tissue so as to engage the inner lining of the pocket wall and junctional epithelium. Curette the soft tissue wall: Curette is carried along the soft tissue, in a horizontal stroke (Figs .1 A and B).& B Figs .1 A and B: Curettage with curette* The pocket wall is supported by gentle finger pressure on the external surface. * Several overlapping strokes are used to completely remove the epithelium and underlying granulation tissue. * In subgingival curettage, the tissues attached between the bottom of the pocket and alveolar crest are removed with a scooping motion of curette to the tooth surface. ° Irrigation: Irrigate the area to remove debris and press the tissue to the tooth surface gently which enables the arrest of bleeding and the adaption of soft tissue to the root surface. ° Suturing: Suture the tissue if necessary. © Post operative instructions are given thereafter.* The pocket wall is supported by gentle finger pressure on the external surface. * Several overlapping strokes are used to completely remove the epithelium and underlying granulation tissue. * In subgingival curettage, the tissues attached between the bottom of the pocket and alveolar crest are removed with a scooping motion of curette to the tooth surface. ° Irrigation: Irrigate the area to remove debris and press the tissue to the tooth surface gently which enables the arrest of bleeding and the adaption of soft tissue to the root surface. © Suturing: Suture the tissue if necessary. © Post operative instructions are given thereafter.Excisional New Attachment Procedure (ENAP): It is subgingival curettage performed with a knife. This technique was developed by US Naval Dental Corps. The stated objectives of the procedure are to allow proper soft tissue preparation, to gain better access to the root surface, and to enable soft tissue to adapt intimately to the root surface. Instruments: Surgical handle (Bard Parker no.3), surgical blades no. 11, 12, 15 and curettes.@ a B Figs .2 A and B: Excisional new attachment procedure© Removal of the tissue: The excised tissue and granulation tissue are removed with curette. Root planing is done after that. ° Irrigation: Irrigate the area with saline. © Suturing: Approximate the wound edges and place suitable sutures. ¢ Postoperative instructions are given.- Ultrasonic Curettage: * Curettage with ultrasonic devices also has been described. Sound energy absorbed at tissue junctions that take the form of heat, results in coagulation. * The coagulated epithelium is then removed by mechanical action of the vibrations of ultrasonic instrument. RChemical Curettage: Sodium sulphide, phenol, camphor, antiformin, and sodium hypochlorite have been used for chemical curettage. Anesthesia is given to the selected site. After isolating the site with cotton rolls, solution of sodium hypochlorite is placed into the pocket for 1 minute. Then 5% citric acid solution is introduced into the pocket for 1 minute to neutralize the sodium hypochlorite. The coagulated tissue is then removed with a curette and pocket is flushed with saline to remove the remnants of the connective tissue. The extent of chemical penetration to the tissue cannot be controlled and thus, chemical curettage is discarded.Laser: b Recently, a method of curettage with a dental laser has been proposed. The goals of laser curettage are epithelial removal, as with previous methods, and in addition, bacterial reduction also. Ashort-term study reported that Nd:YAG laser treatment did not produce statistically significant bacterial reduction.PRESENT CONCEPTS * Short- and long-term clinical trials have confirmed that gingival curettage provides no additional benefit when compared to scaling and root planing alone in terms of probing depth reduction, attachment gain, or inflammation reduction. + After comparing scaling and root planing alone to curettage plus scaling and root planing, it was concluded that curettage “did not serve any additional useful purpose”. * Following an extensive discussion on the topic in the 1989 World Workshop in Clinical Periodontics, it was concluded that curettage had “no justifiable application during active therapy for chronic adult periodontitis”.POINTS TO PONDER * While performing curettage, Gracey curette No. 11-12 is used for distal surfaces of posteriors and Gracey curette No. 13-14 is used for mesial surfaces of posteriors (which is opposite for scaling and root planing). * For gingival curettage blade face to tooth surface angulation is more than 90°.