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Gingivectomy Seminar
Gingivectomy Seminar
Gingivectomy Seminar
Procedures
Seminar by:
Aparna S
Introduction
Contents :
Rationale Minor procedures : Curettage Gingivectomy Crown Lengthening Operculectomy
Frenotomy/ frenectomy
Vestibular deepening procedures Depigmentation Conclusion
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 attachment,
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
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 reduction .
AAP 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
- 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
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
Technique :
Goldman 1951
Prerequisites :
1. Reduced inflammation 2. Functionally adequate zone of attached that must exist apical to the base of the gingival pocket
Clarke :
1. Eliminate gingival pockets
2.
Create aesthetic tooth form & gingival symmetry in cases of delayed passive eruption
and gingival enlargement
3. 4. 5.
Transform rolled/ blunted margins to ideal physiologic form Correct soft tissue craters Gain additional crown length for restorative , endodontic & /or prosthetic purposes
Contraindications :
Hyperemia and edema of tissues
Gingivoplasty:
No pocket elimination
Recontour gingiva
Gingival clefts, craters , shelf like interdental papillae caused by ANUG, gigival enlargement Incision : similar to gingivectomy Taper the gingiva, create scalloped outline, thin attached gingiva, create vertical interdental grooves shape interdental papillae to provide sluiceways
24hrs ct cells , angioblasts 3rd day fibroblastic proliferation Persson et al 1959 2wks capillaries from bv s of pdl 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.crest fibres occur more slowly (Tonna et al 1967 ) - Electrosurgery
Electrosurgery :
Adv : permits contouring of ts and control hemorrhage
unpleasant odour
heat generated tissue damage , loss of pd support touches root areas of cementum burn
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 &
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
Lingual frenectomy :
Tongue tie
Affects speech , movements of the tongue Close to vital structures Careful surgical procedure
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 aesthetics
Loop electrode Stretch the frenum/ muscle section with coagulating current
mucosal injury Edlan and Mejchar (1963) widening of attached non keratinized gingiva Bohannan 1962 : long term results unsuccessful (non graft procedures)
Other techniques :
1. 2. 3. Kazanjian s Lip switch technique (Transpositional Flap Vestibuloplasty) Obwegeser s technique Clark s technique
Operculectomy :
Acute pericoronitis - severity of inflammation
Persistent symptom free flaps prevent infection When? Eruption of tooth in arch
bone
Variations exist : Vacek et al 1994 : BW patient specific Range of 0.75mm 4.3mm Aleast 3mm of sound tooth str above
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
Body s response :
Evaluation :
Evaluate clinically caries, amt of residual tooth structure,
Probing under LA
- BW : marginal gingiva to bone sulcus depth
Objectives :
l. Removal of subgingival caries
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
Procedures :
1. Simple Crown Lengthening - esthetic crown lengthening - short crowns, different gingival margins - gingivectomy/ recountouring
Nd: YAG laser : soft tissue curettage Radvar et al 1996 no statistically significant bacterial reductn Diode laser : Moritz et al 1997 , 98 : repeated application of laser for curettage in comparision with SRP Haytac et al 2006 : frenectomy with CO2 laser reduction in patient perception of pain, hemostasis Cobb 2006 : No evidence to show that lasers are superior to SRP or advantageous over scalpel in soft tissue procedures. Hemostasis and post op discomfort less, 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 Min heating of tissues ablation energy cellular rupture & vaporization
Conclusion
References :
1. Caranza 8 th, 9th ed, 10th edition 2. Lindhe 4th ed 3. Clarke Clinical dentistry : Periodontal and Oral surgery 3rd ed 4. Peterson Oral and Maxillofacial Surgery
8. JP2006,JP2002,
9. Net References
Courage is not always a roar. Sometimes its a quite voice at the end of the day saying I will try again tomorrow.
Thank you.
Have a good weekend !