Minor Periodontal Surgical

Procedures

Seminar by:

Aparna S
Contents :
Rationale
Minor procedures :
Curettage
Gingivectomy
Crown Lengthening
Operculectomy
Frenotomy/ frenectomy
Vestibular deepening procedures
Depigmentation

Conclusion
The goals of surgery are to: *

1) Gain access for root preparation when nonsurgical methods are

ineffective

2) Establish favorable gingival contours

3) Facilitate oral hygiene

4) Lengthen the clinical crown to facilitate adequate restorative

procedures; and
* Hom – Lay Wang , Henry Greenwell perio 2000, 2001
5) Regain lost periodontium using regenerative approaches.
 Curettage :

Scraping of the gingival wall of a periodontal pocket to

separate diseased soft tissue.

 Gingival Curettage : removal of inflamed soft tissue lateral to the pocket wall

 Subgingival curettage : is the procedure that performed apical to the epithelial attachmen

severing the connective tissue attachment down to the osseous cres

 Inadvertant curettage : spontaneous removal of the pocket lining during scaling

and root planing.

Indications :

 Part of new attachment procedures in moderately deep intrabony

pockets –

closed surgery

 Reduce inflammation – pocket elimination surgeries

 Recall visits

 Patients – aggressive surgical techniques contraindicated

Rationale :
 Removes chronically inflammed granulation tissue - fibroblastic and

angioblastic
proliferation , calculus deposits , areas of inflammation
 Lined by deep strands of epithelium – barrier to attachment of new fibres

 Root planing : removal of bacteria resolution of pathologic changes

Existing granulation ts slowly absorbed ,

bacteria destroyed by host defense

Eliminate inflammed granulation tissue ?????

 Carranza 1954, Hirschfield 1952 : Curettage – new attachment
 Caton j et al 1980 : SRP , Curettage – long junctional epithelium
 Gingival curettage : closed surgical procedure – no access to roots
 Ainsle et al , Caffesse et al 1981 , Caffesse RG et al 1983 , Ramjford et al
1981
Gingival curretage – no additional benefit over SRP in terms of PD
reduction,
attachement gain or inflammation
AAPreduction . :
report 2002
Comparing SRP alone to curettage plus SRP, it was concluded that
curettage “did not serve any additional useful purpose.” “no justifiable
application during active therapy for chronic adult periodontitis.”
Technique :
 Other Techniques :
1. ENAP : US Naval Dental Corps 1975, Yukna et al 1976
definitive subgingival curettage procedure

Advantages : 1. Avoid flap reflection, pocket removed

2. Knife edge
3. Allows for debridement
2. Ultrasonic Curettage : (Nadler 1962 )

- Vibrations disrupt tissue continuity, lift off epithelium, dismember collagen bundles
alter morphologic features of fibroblast nuclei – Goldman 1961
- effective for debriding the epithelial lining of pd pckt. – resulting in a narrow band of
of necrotic tissue which strips off the inner lining

3. Caustic agents : Stewart H (1899)

- Induce chemical curettage of lateral wall of pocket
- Sodium sulfide, alk. Sod hypochlorite solution ( Antiformin)
- Antiformin : coagulates the soft tissues – removal of inflammed tissue
Disadv : extent of destruction not controlled.
 Healing after curettage :
Blood clot PMNs

granulation ts – epith – 2-5days

Immature collagen fibres – 21 days

Moskow et al , Waerhaug et al – LJE

Caton JC et al : windows of ct attachmen

Clinical appearance : Immediately

after 1 week
after 2 weeks
Gingivectomy :

 Introduced by Robicsek in 1884 , described by Grant et al 1987

 Resect / excise the soft tissue wall of the pocket – POCKET ELIMINATION
 Gingivoplasty : recontour gingiva that has lost its physiologic outer form
 Rationale :

Removes the diseased pocket wall that obscures the tooth surface

visibility and accessibility for complete removal of surface deposits and planing of roots

Favourable environment for gingival healing – restoration of physiologic gingival contour

 Technique :

Goldman 1951
Prerequisites :

1. Reduced inflammation
2. Functionally adequate zone of attached that must exist
apical to the base of the gingival pocket

Indications :

Glickman 1956 :
1.Eliminate gingival / suprabony pockets
2.Eliminate gingival enlargements
3.Eliminate suprabony periodontal abcesses
Clarke :

1.Eliminate gingival pockets

2.Create aesthetic tooth form & gingival symmetry in cases of delayed passive eruption

and gingival enlargement

3.Transform rolled/ blunted margins to ideal physiologic form

4.Correct soft tissue craters

5.Gain additional crown length for restorative , endodontic & /or prosthetic purposes
Contraindications :

 Hyperemia and edema of tissues

 Pocket extends beyond the MGJ

 Functionally inadequate gingiva

 Interdental / osseous infrabony craters, defects

 Thick buccal / lingual ledges , exostoses

 Short / shallow palatal vault

Ledge and Wedge approach :Oschenbien 1965

Objective : remove all gingiva coronal to the bottom of the gingival sulcus

Technique :
 Gingivoplasty:

 No pocket elimination

 Recontour gingiva

 Gingival clefts, craters , shelf like interdental papillae caused by ANUG, gigival enlargem

 Incision : similar to gingivectomy

 Taper the gingiva, create scalloped outline, thin attached gingiva, create vertical

interdental grooves shape interdental papillae to

provide sluiceways
Healing after gingivectomy :

Surface clot (mins ) within 12hrs , necrotic debris and monolayer of PMNs

24hrs – ct cells , angioblasts

3rd day – fibroblastic proliferation

Persson et al 1959

2wks – capillaries from bv s of pd

Epith complete 5 – 14 days migrate into the granulation ts –

connect with gingival vessels
 Stanton et al 1969 – complete epithelialization takes about 1 month
 Complete repair – 7 weeks
Other methods :
- Chemical method : 5 % paraformaldehyde (Orban 1942) , Pot. Hydroxide (Loe H )
disadv : excessive tissue injury
- gingival remodeling no effective
- epith & reformation of JE and reestablishment of the alv.cres
fibres occur more slowly (Tonna et al 1967 )
- Electrosurgery
 Electrosurgery :

 Adv : permits contouring of ts and control hemorrhage

 Disadv : noncompatible/ poorly shielded cardiac pacemakers

unpleasant odour
heat generated – tissue damage , loss of pd support
touches root – areas of cementum burn
 Uses : gingival enlargements , gingivoplasty, relocation of frenum
& muscle attachments , incision of pd.abscesses, pericoronal flaps
 Technique : needle electrode + small ovoid loop / diamond shaped electrodes
for festooning
- shaving gentle motions : fully rectified current
 Healing after electrosurgery :

Fisher et al 1983, Malone et al 1969 : no difference btw scalpel , electrosurgery

Pope et al 1968 : difference – delayed healing , greater reduction in gingival height ,

more bone injury

Glickman & Imber : gingival recession , bone necrosis & sequestration , loss of bone ht,

furcation exposure , tooth mobility

 Frenectomy / frenotomy :
Frenum : band of fibrous tissue covered with mucosa extending from the lip , tongue &
cheek to the alveolar periosteum
Types of frenal attachments
Effects ?
Indications
- if adequate gingiva is present coronal to the frenum , no need to remove it
surgically
Frenotomy : relocating frenal attachment to create a zone of attached
gingiva btw
gingival margin & frenum
 Frenectomy : excising the frenum , including its attachment to bone

Rationale : frenum that encroaches on the margin of the gingiva – interfere

with plaque removal, increase rate of periodontal recession and recurrence
after treatment
Other Techniques :

Edward ‘s Technique :
 Z plasty :
 Thick fibrous frenum

Adv : may decrease amt of vestibular ablation sometimes seen after linear excision
of a frenum
Frenotomy with vestibuloplasty

 When the base of the frenum is wide

 Mandibular anterior frenal attachments
Lingual frenectomy :

 Tongue tie

 Affects speech , movements of the tongue

 Close to vital structures
 Careful surgical procedure
 Frenectomy / frenotomy - Orthodontic treatment

Early studies – frenectomy prior to orthodontic treatment – cause for diastema

Now : delayed surgical treatment – permanent teeth erupt
difficulty in moving teeth through scar tissue & self correcting nature
Edwards JG 1977 : 77% reduction in opening of diastema when frenectomy after
orthodontic treatment
Miller 1985

 Frenectomy – interdental papilla undisturbed.

 A pedicle graft laterally positioned across the midline to obtain

primary closure gingiva across the midline ; not scar
tissue.
 Gingivoplasty labially or palatally to remove any excessive
tissue.
 Objective : obtain orthodontic stability without compromising the

Miller PD. The frenectomy combined with a laterally positioned

aesthetics
pedicle graft. Functional and aesthetic considerations.
J Periodontol l985: 56: 102-106.
Electrosurgery for abberrant frenum :

Loop electrode

Stretch the frenum/ muscle – section with coagulating current

Vestibular deepening procedures :

 Shallow vestibule – difficulty in brushing – plaque accumulation

mucosal injury
 Edlan and Mejchar (1963) widening of attached non keratinized gingiva
 Bohannan 1962 : long term results – unsuccessful (non graft procedures)
 Other techniques :

1. Kazanjian s Lip switch technique (Transpositional Flap Vestibuloplasty)

2. Obwegeser ‘s technique

3. Clark s technique
 Operculectomy :

Acute pericoronitis - severity of inflammation

Persistent symptom free flaps – prevent infection
When?
Eruption of tooth in arch
Bone loss distal to 2nd molar
Extract or retain??
If retained : pericoronal flap removed
 Crown lengthening procedures :
Short clinical crowns : unaesthetic , inadequate for retention of restorations
Methods to increase crown length : surgically – gingivectomy
Flap surgery with osteotomy/ osteoctomy
Orthodontic extrusion .
Biologic width : dimension of space that healthy gingival tissues occupy above the alveola
bone

Garguilo , Wentz, Orban 1961

Variations exist :

Vacek et al 1994 : BW – patient specific

Range of 0.75mm – 4.3mm

Aleast 3mm of sound tooth str – above

the alveolar crest
-If gingiva thick with adequate att gingiva – gingivectomy
-Otherwise – apically repositioned flap with osseous resection

If margin of restoration subgingival : atleast 3mm

equigingival : atleast 4mm
 Why ?
To diagnose BW violation when restorative margin is placed 2mm
or less
away from the alveolar bone and the gingival tissues are inflammed
with
no other etiologic factors evident.
Restorations : supragingival, equigingival or subgingival
Subgingival : create adequate resistance and retentive form
caries / tooth deficiencies
mask the tooth- restn margin
Body s response :
 Evaluation :
 Evaluate clinically – caries, amt of residual tooth
structure,
 Evaluate the gingival morphology- post treatment
gingival margins
Radiographs
 Probing under LA
- BW : marginal gingiva to bone – sulcus depth
Objectives :
l. Removal of subgingival caries
2. Enabling restorative treatment without impinging on
biologic width
3. Correction of occlusal plane
4.Facilitation of improved oral hygiene
5. Cosmetic improvement
Diagnostic considerations include:

l. Subgingival caries and the degree of extension of the clinical crown

fracture apically
2. Whether the clinical crown/root ratio after restorative treatment may
be unfavorable
3. Root length and root morphology
4. Residual amount of supporting bone after crown lengthening
(especially
osseous resection)
5. The degree of periodontal support lost from the adjacent
tooth
6. The possibility of furcation exposure as well as unfavorable
exposure of root surface (including grooves), which may
complicate maintenance
7. Increasing tooth mobility due to diminished supporting
tissue and its influence on occlusion
8. Whether proper plaque control can be maintained after the
placement
Procedures :

1. Simple Crown Lengthening - esthetic crown lengthening

- short crowns, different gingival margins
- gingivectomy/ recountouring
2. Compound crown lengthening : functional lengthening
Lasers The New Scalpel????

Lasers – Nd:YAG, CO2 , Er: YAG – soft tissue procedures

FDA clearance – 1976
Pick RM et al 1985 – CO2 laser – gingivectomy
CO2 laser – gingivectomy , gingivoplasty, frenectomy, adjunct to
non surgical & surgical procedures
Nd: YAG laser , diode laser …
Aoki et al 1994 , Schwarz et al 2001, Walsh 2003, Haytac et al 2006,
d: YAG laser : soft tissue curettage Radvar et al 1996 – no statistically significant
bacterial reductn

iode laser : Moritz et al 1997 , ‘98 : repeated application of laser for curettage in
comparision with SRP
aytac et al 2006 : frenectomy with CO2 laser – reduction in patient perception
of pain, hemostasis

obb 2006 : No evidence to show that lasers are superior to SRP or advantageous over
scalpel in soft tissue procedures. Hemostasis and post op discomfort les
healing delayed … (AAP Review)
 Depigmentation

 Melanin, bilirubin, iron, metals – bismuth, amalgam etc..

 Physiologic / pathologic
 Rationale : aesthetics!!!
 Criteria for case selection :
- disparity btw skin tone & gingival colour
- healthy periodontium
- adequate thickness of the tissues
 Techniques – chemical , cryosurgery, surgical , electrosurgery, lasers
- Gingivoabrasion
- Split thickness epithelial excision
- Combination
Depigmentation
 Depigmentation – Lasers :

Non specific beam laser – ablate melanocytes

Er:YAG laser – 500 mJ – pulsed *

Radiation energy ablation energy cellular rupture & vaporization

Min heating of tissues

* Tal H et al 2003 – Gingival depigmentation by Er:YAG laser: clinical observations

and patient responses.

Conclusion
 References :

1. Caranza 8 th, 9th ed, 10th edition

2. Lindhe – 4th ed
3. Clarke – Clinical dentistry : Periodontal and Oral surgery 3 rd ed
4. Peterson – Oral and Maxillofacial Surgery
5. Sato – Clinical Atlas
6. Ratnadeep Patil – Aesthetic Dentistry
7. Perio 2000 – 2004, 2001, 1995, 1996
8. JP2006,JP2002,
9. Net References
Courage is not always a roar. Sometimes it’s a quite voice

at the end of the day saying “ I will try again tomorrow.”

Thank you.

Have a good weekend !