gingival surgical technique ppt

1. Gingival
surgical
techniques
Shazia fathima
IIIrd year

2. Limited to the gingival region and do not involve
underlying osseous structures
• Gingival Curettage
• Gingivectomy
• Gingivoplasty

3. History
John W Riggs (1811-1885)
In an 1876 paper, Riggs was a strong proponent of the
so-called conservative approach to periodontal therapy.
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.

4. 1902 –Znamensky
published the classic paper ”Alveolar Pyorrhea – Its
pathological anatomy and its radical treatment. He treated
Pyorrhea with removal of calculus and also deep curettage of
the sockets, using cocaine anesthesia
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.

5. 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.

6. GINGIVAL CURETTAGE

7. Introduction
Bacterial Plaque causes the formation of
Periodontal Pockets and resorption of
alveolar bone due to apical migration of
Junctional Epithelium

8. Treatment Of
Periodontal Pockets
Pocket Reduction Pocket Elimination

10. Definition
• The term "gingival curettage" implies directing an
operative instrument against the gingival wall of the
periodontal pocket in order to remove the ulcerated
epithelium covering the sulcus. Thus, curettage is the
conversion of a chronic inflammatory ulcer in the
gingival wall of the pocket into a surgical wound - (
Nestor & Lopez ,1977)
• 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 )

11. •Terminology -
• 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.
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12. Rationale For Curettage
• 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

13. It has been shown that scaling and root planing with
additional curettage do not improve the condition of the
periodontal tissues beyond the improvement resulting from
scaling and root planing alone.

14. • Curettage may also eliminate all or most of the epithelium
that lines the pocket wall & underlying Junctional
Epithelium
- Moskow BS 1964, Beube FE 1953, Sato M 1960

15. Curettage and Esthetics
• In the past, pocket elimination was the primary
goal of therapy, and little regard was given to the
esthetic result. Maximal, rapid shrinkage of
gingival tissue was the aim to eliminate the
pocket.

16. • Currently, esthetics is a major consideration of therapy,
particularly in the anterior maxilla (teeth #6-11), and
requires preservation of the interdental papilla.

17. • When reconstructive therapy is not possible, every
effort should be made to minimize shrinkage or loss
of interdental papilla
• Compromise Therapy – Avoiding Gingival Curettage
• Papilla Preservation Technique
• Root Planing apical to the base of the pocket

18. • Another important precaution involves root planing
apical to the base of the pocket. The removal of the
junctional epithelium and disruption of the connective
tissue attachment expose the non-diseased portion of
the cementum.
• Root planing in this area of non-diseased cementum may
result in excessive shrinkage of the gingiva, increasing
recession or requiring "new attachment" where no
disease previously existed.

19. Indications For Curettage
• Very Limited
• They can be used after SRP for the following
purposes:
Can be performed as a part of new attachment
attempts in moderately deep intrabony pockets in
accessible areas where a type of “closed” surgery is
deemed advisable.
Non definitive procedure to reduce inflammation or
when other surgical procedures are contra-indicated.
On recall visits – Ramfjord 1979

20. Contraindications :
• Deep pockets ≥ 5mm
• Furcation involvements
• Medically compromised patient
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21. Procedure

22. Basic Technique
• Curettage does not eliminate the causes of
inflammation and therefore should be preceded by
SRP.
• It requires local anesthesia.

23. The curette is selected so that the
cutting edge is against the tissue
(e.g., Gracey #13-14 for mesial
surfaces, Gracey #11-12 for distal
surfaces).
Curettage can also be performed
with a 4R-4L Columbia Universal
curette.
The instrument is inserted so as to
engage the inner lining of the
pocket wall and is carried along the
soft tissue, usually in a horizontal
stroke .
The pocket wall may be supported
by gentle finger pressure on the
external surface. The curette is then
placed under the cut edge of the
junctional epithelium to undermine
it.
Gingival curettage performed with a horizontal
stroke of the curette.

24. In subgingival curettage, the
tissues attached between the
bottom of the pocket and the
alveolar crest are removed
with a scooping motion of the
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.
In some cases, suturing of
separated papillae and
application of a periodontal
pack may be indicated.
Subgingival curettage.
A,Elimination of pocket lining.
B,Elimination of junctional
epithelium and granulation tissue.
C, Procedure completed.

25. Other Techniques
• Other techniques for gingival curettage include
1. The excisional new attachment procedure,
2. Ultrasonic curettage, and
3. The use of caustic drugs.

26. EXCISIONAL NEW ATTACHMENT PROCEDURE
(ENAP)
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
Developed by the U.S Naval Dental Corps based on studies by
Yukna and colleagues (1976),
Gain new attachment
Decrease probing depth
Access root surface

27. 1. 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. (the intention is to cut the
inner portion of the soft tissue wall
of the pocket , all around the tooth
Excisional new attachment procedure.
A, Internal bevel incision to point below
bottom of pocket.
B, After excision of tissue, scaling and root
planing are performed.
3.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.
2. Remove the excised tissue with a
curette and perform root planing on all
exposed cementum to achieve a
smooth hard surface.

28. Author Studies Result
Yukna et al,1976 Excisional new attachment
procedure was used to treat
75 suprabony pockets on 32
teeth in 9 patients
One-year postoperative -
mean pocket reduction from
4.7 mm to 2.0 mm, of which
2.1 mm (77%) was new
attachment and 0.6 mm was
recession.
Yukna and Williams Jr,1980 Patients treated with the
Excisional New Attachment
Procedure were evaluated 5
years or more following the
procedure
An overall mean net gain in
clinical attachment of 1.5 mm
was found at 5 years after
treatment, and probing
depths approached 3.0 mm

29. 29

30. 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. The flaps were then
sutured at the presurgical height . The technique is basically the same in all other
aspects
A. Initial incision made to
the crest of bone of the
pocket
B. Inner wall removed down
to the crest of bone &
periodontal ligament
C. Healed tissue
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31. • The use of ultrasonic devices has been recommended for gingival curettage.
• When applied to the gingiva of experimental animals, ultrasonic vibrations
disrupt tissue continuity, lift off epithelium, dismember collagen bundles,
and alter the morphologic features of fibroblast nuclei.
• 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.
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Ultrasonic Curettage

32. Since early in the development of periodontal procedures, 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),
phenol
These drugs were discarded after studies showed their ineffectivene
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 (Kenneth – 1981) (Lorraine et al-1986
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Caustic Drugs

33. Healing After Curettage
• Immediately after curettage, blood clot fills the
pocket area which is totally or partially devoid of
epithelial lining.
• Hemorrhage is also present in tissues with dilated
capillaries and abundant PMN’s appear shortly
thereafter on the wound surface. This is followed
by a rapid proliferation of granulation tissue, with
decrease in number of small blood vessels.
• Restoration of sulcus generally requires 2-7 days
and restoration of JE in animals occur in 5 days.

34. • Immature collagen fibres appear within 21 days.
• Healthy gingival fibers inadvertently severed from
tooth and tears in epithelium are repaired in
healing process.
• Healing results in the formation of long JE with no
CT in humans -Waerhaugh 1978
• In some cases long JE is interrupted by
“Windows” of CT attachment - Caton JC 1979

35. CLINICAL APPEARANCE AFTER SCALING 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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36. GINGIVAL CURETTAGE – RELEVANCE
•Gingival curettage and debridement of soft tissue wall of
the pocket as an adjunct to SRP seems to offer no
advantage in the initial healing response over SRP alone.
•Removal vs non removal of granulation tissue during
flap surgery and non surgical therapy (SRP) was studied
by Lindhe & Nyman (1985). The results failed to show an
advantage of granulation tissue removal.
•Studies provide convincing evidence that SRP alone
produce results clinically equivalent to curettage plus SRP.

37. • The various methods used for epithelial removal show
that they have no advantage over mechanical
instrumentation with curette.
• Therefore gingival curettage by whatever method
performed should be considered as a procedure that
has no additional benefit to SRP alone in treatment of
chronic periodontitis.

38. AAP- statement regarding gingival
curettage
• 1989 world workshop in clinical periodontics
concluded that curettage had ‘ no justifiable
application during active therapy for chronic adult
periodontitis’
• Curettage is a procedure which provides historic
interest in the evolution of periodontal therapy
but has no current clinical relevance in the
treatment of chronic periodontitis
(AAP Academy Report 2002)

39. GINGIVECTOMY

40. Gingivectomy
• Grant et al 1979 - Excision of soft tissue wall of
pathologic periodontal pocket.
• Gingivectomy means excisions of the gingiva.
• By removing the pocket wall, Gingivectomy
provides visibility and accessibility for complete
calculus removal and thorough smoothing of
roots, creating a favorable environment for
gingival healing and restoration of physiological
contour.

41. The gingivectomy technique
was widely performed in
the past.
Improved understanding of
healing mechanisms and the
development of more
sophisticated flap methods
have relegated the
gingivectomy to a lesser
role in the current
repertoire of available
techniques.
However, it remains an
effective form of treatment
when indicated . Results obtained by treating a suprabony pocket with
gingivectomy. A, Before treatment. B, After
treatment.

42. Indications
• Elimination of suprabony pockets, regardless of
their depth, if the pocket wall is fibrous and firm.
• Elimination of gingival enlargements.
• Elimination of suprabony periodontal abscesses.
Glickman - 1956

43. Contraindications
• The need for bone surgery or examination of the bone
shape and morphology.
• Situations in which the bottom of the pocket is apical to
the mucogingival junction.
• Esthetic considerations, particularly in the anterior maxilla.

44. Various techniques of GINGIVECTOMY
Surgical gingivectomy
Gingivectomy by electrosurgery
Laser gingivectomy
Gingivectomy with chemosurgery

45. Surgical Technique
• 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.

46. Step 2:
• Periodontal knives (Kirkland knives)
• Orban periodontal knives
• Bard-Parker knives # 11 and # 12 and scissors.

47. • 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

48. • Discontinuous or continuous incisions may be
used
• Incision should be beveled at 450 to the tooth
surface

49. Step 3:
• Remove excised pocket wall
• Clean the area
• Examine the root surface

50. Step 4 :
• Curette granulation tissue
• Remove any remaining necrotic cementum or
calculus

51. Step 5:
• Cover the area with surgical pack

52. • Robicsek (1884) – Straight incision technique

53. • Zentler (1918) – Scalloped incision technique

55. PERIODONTAL KNIVES

60. A, Discontinuous incision apical to bottom of the
pocket indicated by pinpoint markings. B, Continuous
incision begins
on the molar and extends anteriorly without interruption

68. • Initially, formation of a protective surface clot.
• Underlying tissue becomes acutely inflamed, with
some necrosis.
• The clot is then replaced by granulation tissue.
Healing after GINGIVECTOMY

69. • By 24 hours, there is an increase in new connective tissue cells
mainly angioblasts, below the surface of inflammation.
• By the 3rd day, numerous young fibroblasts are located in the
area.
• This highly vascularized connective tissue grows coronally,
creating a new, free gingival margin and sulcus.

70. • After 12 to 24 hours, epithelial cells at the margins of the
wound start migrating over the granulation tissue.
• Epithelial activity reaches a peak in 24 to 36 hours.
• After 5 to 14 days, surface epithelialization is generally
complete.
• Complete repair takes about 1 month.

71. GINGIVECTOMY BY electrosurgery
ADVANTAGES:
Control of hemorrhage.
 Adequate contouring of the tissue.

72. DISADVANTAGES:
• Cannot be used in patients who have poorly shielded cardiac
pacemakers.
• Treatment causes unpleasant odor.
• If the electro surgery point touches the bone, irreparable damage can be
done.

73. • The heat generated by injudicious use can cause
tissue damage and loss of periodontal support
when the electrode is used close to the bone
• when electrode touches the root, areas of
cementum burn are produced.

74. Technique
• Removal of gingival enlargements and gingivoplasty is performed with
the needle electrode.
• Small, ovoid loop or the diamond shaped electrodes are used for
festooning.
• In all reshaping procedures, electrode is activated and moved in a concise
“shaving” motion.
• For hemostasis, the ball electrode is used.

75. For Acute Periodontal Abscess
◘ Drainage with needle electrode without exerting
painful pressure
◘ Followed by regular procedure

76. • Frenum – Loop electrode
• Acute Pericornitis – Bent needle electrode

78. Healing After Electrosurgery
• Fisher SE 1983 – No significant differences
• Pope JW 1968 – Delayed healing
• Glickman J 1970 – Necrosis , Sequestration , Loss of
bone height , furcation exposure & tooth mobility

79. Laser GINGIVECTOMY
The lasers most often used in dentistry are the
carbon dioxide (CO2) and neodymium:yttrium-
aluminum-garnet (Nd:YAG) with the wavelength of
10,600nm and 1064nm respectively.

80. • The 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 neighboring tissues and eyes of the operator.

81. Gingivectomy By Chemosurgery
• 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 occurs slowly –
Tonna E 1967
• Not recommended

82. 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

83. Procedure:
• Tapering the Gingival Margin
• Creating scalloped marginal outline
• Thinning of attached gingiva
• Creating vertical interdental grooves
• Shaping interdental papilla

84. C. Gingivoplasty. D. 8 weeks postsurgically.

85. Conclusion
Current understanding of disease etiology &
therapy limits the use of these techniques
, but their place in surgical therapy is
essential….

86. thankyou

87. References

88. • Carranza 10th edition
• Lindhe J, Nyman S. The effect of plaque control and
surgical pocket elimination on the establishment and
maintenance of periondontal health. A longitudinal study
of periodontal therapy in cases of advanced disease. J Clin
Periodontol 1975;2:67–79.
• Stern T, Everett F, Robicsek K. S. Robicsek a pioneer in the
surgical treatment of periodontal disease. J Periodontol
1965;36:265–268.
• The American Academy of Periodontology; Glossary of
Periodontal Terms, 3rd ed. Chicago; The American Academy
of Periodontology; 1992
• The american academy of periodontology statement
regarding gingival curettage – JOP 2002
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