GINGIVAL SURGICAL TECHNIQUES

Periodontal pocket reduction surgery limited to the gingival tissues only and not involving the udentifying osseoud structures, without the use flap surgery, can be classified as gingival curettage and gingivectomy. Current understanding of disease etiology and therapy limits the use of both techniques, but their place in surgical therapy is essential.

Gingival Curettage The word curettage is used in periodontics to meant the scraping of the gingival wall of a periodontal pocket to separate diseased of tissue. Scalling refers to the removal deposits from the root surface, whereas planing means smoothing the root to remove infected and necrotic tooth substance. Scalling and root planing may inadvertently include various degrees of curettage. However, they are different procedures, with different rationales and indications, and should be considered separate parts of periodontal treatment. A differentiation has been made between gingival and subgingival curettage. Gingival curettage consists of the removal of the inflamed soft tissue lateral to the pocket wall, whereas subgingival refers to the procedure that is performed apical to the epithelial attachment, severing the connective tissue attachment down to the osseous crest. It should also be understood that some degree of curettage is done unintentionally when scalling and root planning are performed; this is called inadvertent curettage. This chapter refers to purposeful curettage performed during the same visit as scalling and root planing, or as a separate procedure, to reduce pocket depth by enchancing gingival shrinkage, new connective tissue attachment, or both.

Rationale Curettage accomplishes the removal of the chronically inflamed granulation tissue that form in the lateral wall of the periodontal pocket. This tissue, in addition to the usual components of granulation tissue (fibroblastic and angioblastic proliferation), contains areas of chronic inflammation and mayb also have pieces of disloged calculus and bacterial colonies. The latter may perpetuate the pathologic features of the tissue and hinder healing.

This inflamed granulation tissue is lined by epithelium, and deep stands of epithelium penetrate into the tissue. The presence of this epithelium of new fibers in the area. When the root is through planed,and the major source of bacteria disappears, and the pocket pathologic changes resolve with no need to eliminate the inflamed granulation tissue by curettage. Thye existing granulation tissue is slowly resorbed; the bacteria present, in the absence of replenishment of their numbers by the pocket plaque, are destroyed by the defense mechanisms of the host.therefore the need for curettage only to eliminate the inflamed granulation tissue appears questionable. It has been shown that scalling 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. Curettage may also eliminate all or most of the epithelium that lines the pocket wall and the underlying junctional epithelium. This purpose of curettage is still valid, particularly when an attempt is made at new attachment, as occurs in intrabony pockets. However, opinions differ regarding whether scaling and curettage consistently remove the pocket lining and the junctional epithelium. Some investigators report that scaling and root planing tear the epithelial lini9ng of the junctional epithelium, but that both epithelial structures, sometimes including underlying inflamed connective tissue, are removed by curettage. Other investigators report that the removal of the pocket lining and junctional epithelium by curettage is not complete.

Curettage and Esthetics The awareness of esthetics in periodontal therapy has become an integral part of care in the modern practice of periodontics. 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. Currently, esthetics is a major consideration of therapy, particularly preservation of the interdental papilla. When reconstructive therapy is not possible, every effort should be made to minimize shrinkage or loss of the interdental papilla. A compromise therapy that is feasible in the anterior maxilla, where access is not difficult, consists of through subgingival root planing , attempting not to detach the connective tissue beneath the pocket and avoiding gingival curettage. The granulation tissue in the lateral wall of the pocket, in an environment free of plaque and calculus, becomes connective tissue, thereby minimizing shrinkage. Thus, although complete pocket elimination is not accomplished, the inflammatory changes are reduced or eliminated while the interdental papilla and the esthetic appearance of the area are preserved.

Surgical techniques specially designed to preserve the interdental papilla, such as the papilla preservation techniques. Result in better esthetic appearance of the anterior maxilla than to aggressive scaling and curettage of the area. 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 gingival, increasing recession or requiring new attachment where no disease previously existed.

Indications Indications for curettage are very limited. It can be used after scaling and root planing for the following purpose: 1. Curettage can be performed as part of new attach,emt attempts in moderately deep intrabony pockets located in accessible areas where a type of closed surgery is deemed advisable. However, technical difficulties and inadequate accessibility frequently contraindicate such surgery. 2. Curettage can be done as a non definitive procedure to reduce inflammation before pocket elimination using other methods or when more aggressive surgical techniques are contraindicated in patients because of their age, systemic problems, psychologic problems, or other factors. It should be understood that in this patients, the goal of pocket elimination is compromised and prognosis is impaired. The clinician should resort to this approach only when the indicated surgical techniques cannot be performed, and both the clinician and the patient must have a clear understanding of limitations. 3. Curettage is also frequently performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket depth, particularly where pocket reduction surgery has previously been performed. Careful probing should establish the extent of the required root planing and curettage to avoid unnecessary shrinkage, pocket formation, or both.

Procedure Basic Technique

Curettage does not eliminate the causes of inflammation (bacterial plaque and deposits). Therefore, curettage should always be preceded by scaling and root planing , the basic periodontal therapy procedure. The use of local infiltrative anesthesia for scaling and root planing is optional. However, gingival curettage always requires some type of local nesthesia. The curette is selected so that the cutting edge will be against the issue. 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.

Other Technique Other technique for gingival curettage include the excisional new attachment procedure, ultrasonic curettage, and the use of caustic drugs: Excisional New Attachment Procedure (ENAP). ENAP has been developed and used by the U.S. naval Dental Corps. It is a definitive subgingival curettage procedure performed with a knife. The technique is as follows: 1. After adequate anesthesia, make an internal bevel incision form the margin of the free gingival apically to a point below the bottom of the pocket. Carry the incision interproximally on both the facial and the lingual side, attempting to retain as much interproximal tissue as possible. The intention is to cut the inner portion of the soft tissue wall of the pocket, all around the tooth. 2. Remove the excised tissue with a curette, and carefully perform root planing on all exposed cementum to achieve a smooth, hard consistency. Preserve all connective tissue fibers that remain attached to the root surface. 3. Approximate the wound edges; if they do not meet passively, recontour the bone until good adaption of the wound edges is achieved. Place sutures and a periodontal dressing. Ultrasonic Curettage. The use if ultrasonic devices has been recommended for gingival curettage. When applied to the gingival of experimental animals, ultrasonic vibrations disrupt tissue continuity, lift off epithelium, dismember collagen bundles, and alter the morphologic features of fibroblast nuclei. Ultrasound is affective for 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. Some investigators found ultrasonic instruments to be as effective as

manual instruments for curettage but resulted in less inflammation and less removal of underlying connective tissue. The gingival can be made more rigid for ultrasonic curettage by injecting anesthetic solution directly into it. Caustic Drugs. 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 alfide, alkaline sodium hypochlorite solution (Antiformin), and phenol have been proposed and then discarded after studies showed their ineffectiveness. The extent of tissue destruction with this drugs cannot be controlled, and they may increase rather than reduce the amount of tissue to be removed by enzymes and phagocytes.

Healing after Scaling and Root Planing Immediately after curettage, a blood clot fills the pocket area, which is totally or partially devoid of epithelial lining. Hemorrhage is also present in the tissues with dilated capillaries, and abundant polymorphonecluear leukocytes (PMNs) appear shortly thereafter on the wound surface. This is followed by a rapid proliferation of granulation tissue, with a decrease in the number of small blood vessels as the tissue matures. Restorations and epithelialization of the sulcus generally require 2 to 7 days, and restoration of the junctional epithelium occurs in animals as early as 5 days after treatment. Immature collagen fibers appear whitin 21 days. Healthy gingival fibers inadvertently severed from the tooth and liquid in the epithelium are repaired in the healing process. Several investigators have reported that in monkeys and humans treated by scaling procedures and curettage, healing results in the formation of a long, thin junctional epithelium with no new connective tissue attachment. In some cases, this long epithelium is interrupted by windows of connective tissue attachment.

Clinical Appearance after Scaling and Curettage Immediately after scaling and curettage, the gingival appears hemorrhagic and bright red. After 1 week, the gingiva appears reduced in height because of an apical shift in the position of the gingival margin. The gingiva is also slightly redder than normal, but much less so than on previous days. After 2 weeks and with proper oral hygine by the patient, the normal color, consistency, surface texture, and contour of the gingival are attained, and the gingival margin is well adapted to the tooth.

Gingivectomy Gingivectomy means excision of the gingiva. By removing the pocket wall, gingivectomy provides visibility and accessibility for complete calculus removal and through smoothing of the roots, creating a favorable environment for gingival healing and restoration of a physcologic gingival contour. The gingivectomy technique was widely performed in the past. Improved understanding of healing mechanism 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. Indication and Contraindications The gingivectomy technique may be performed for the following indications: 1. Elimination suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm. 2. Elimination of gingival enlargements. 3. Elimination of suprabony periodontal abcesses. Contraindications to gingivectomy include the following: 1. The need for bone surgery or examination of the bone shape and morphology. 2. Situations in which the bottom of the pocket is apical to the mucogingival junction. 3. Esthetic considerations, particularly in the anterior maxilla. The gingivectomy technique may be performed by means of scalpels, electrodes, lasers, or chemicals. All these techniques are reviewed here, although the surgical method is the only technique recommended.

Surgical Gingivectomy Step 1. The pockets on each surface are explored with a periodontal probe and marked with a pocketmarker. Each pocket is marked in several areas to outline its course on each surface. Step 2. Periodontal knives are used for incisions on the facial and lingual surfaces and those distal to the terminal tooth in the arch. Orban periodontal knives are used

for supplemental interdental incisions, if necessary, and bard-Parker knives #11 and #12 and scissors are used as auxiliary instruments. The incision started apical to the points marking the course of the pockets and is directed coronally to a point between the base of the pocket and the crest of the bone. It should be as close as possible to the bone without exposing it, to remove the soft tissue coronal to the bone. Exposure of the bone is undesirable. If it occurs, healing usually presents no problem if the area is adequately covered by the periodontal pack. Discontinuous or continuous incisions may be used. The incision should be beveled at approximately 45 degrees to the tooth surface, as far as possible, the normal festooned pattern of the gingival. Failure to bevel leaves a broad, fibrous plateau that takes more time than usually required to develop a physiologic contour.