GINGIVAL CURETTAGE AND GINGIVECTOMY Dr. Malek Abdulmatlob

Describe Gingival Curettage Rationale Indications Procedure Healing after Scaling and Curettage Clinical Appearance after Scaling and Curettage t

Gingival curettage: It is the scraping of the gingival wall of a periodontal pocket to separate diseased soft tissue. Rationale : 1- It removes chronically inflamed granulation tissue that forms in the lateral wall ( inner surface) of the periodontal pocket→→→ remove barrier for C.T attachment . 2- enhance gingival shrinkage thus reducing pocket depth

Types: 2-subgingival curettage 1-gingival curettage It is the removal of the inflamed soft tissue lateral to the pocket wall It is performed apical to the epithelial attachment, severing the C.T attachment down to the osseous crest.

Indications: 1-removal of suprabony pockets located in accessible areas & having inflamed oedematous pocket wall. 2-new attachment attempts in moderately deep intrabony pockets located in accessible areas

3-to reduce inflammation prior to pocket elimination using other methods or in patients in whom more aggressive surgical techniques (e.g., flaps) are contraindicated owing to age, systemic problems, psychologic problems. 4-as a method of maintenance treatment for areas of recurrent inflammation

PROCEDURE: it should always be preceded by scaling and root planing, as it does not eliminate the causes of inflammation (i.e., bacterial plaque and deposits).

Basic procedure: 1- local anesthesia 2- The curette is selected so that the cutting edge will be against the tissue to engage the inner lining of the pocket wall and carried along the soft tissue in a horizontal stroke.

Subgingival curettage. A, Elimination of pocket lining. B, Elimination of junctional epithelium and granulation tissue. C, Procedure completed.

The pocket wall may be supported by gentle finger pressure on the external surface. 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. Sometimes suturing of separated papillae and application of a periodontal pack may be indicated.

Healing after scaling and curettage: 1- Immediately after curettage, a blood clot fills the pocket area. 2- followed by a rapid proliferation of granulation tissue, with a decrease in the number of small blood vessels as the tissue matures. 3- Restoration and epithelialization of the sulcus generally require from 2 to 7 days.

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, slightly redder than normal. After 2 weeks and with proper oral hygiene by the patient, the normal color, consistency, surface texture, and contour of the gingiva are attained, and the gingival margin is well adapted to the tooth.

Excisional New Attachment Procedure (ENAP): It is a definitive subgingival curettage procedure performed with a knife.

1. After adequate anesthesia, an internal bevel incision is made from the margin of the free gingiva apically to a point below the bottom of the pocket.

The incision is carried interproximally on both the facial and the lingual sides. 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 root plane all exposed cementum to a smooth, hard consistency. Preserve all connective tissue fibers that remain attached to the root surface. 3. Approximate the wound edges. Place sutures and a periodontal dressing.

Ultrasonic Curettage: is effective for debriding the epithelial lining of periodontal pockets. (ultrasonic vibration). The Morse scaler-shaped and rod-shaped ultrasonic instruments are used for this purpose. The gingiva can be made more rigid for ultrasonic curettage by injecting anesthetic solution directly into it.

Caustic Drugs: the use of caustic drugs has been recommended to induce a chemical curettage of the lateral wall of the pocket. Drugs such as sodium sulfide, alkaline sodium hypochlorite solution (Antiformin), and phenol have been proposed and then discarded after studies showed their ineffectiveness. The extent of tissue destruction with these drugs cannot be controlled.

Gingivectomy

Describe Gingivectomy Indications and Contraindications Surgical Gingivectomy Gingivoplasty Healing after Surgical Gingivectomy Gingivectomy by Electro surgery Laser Gingivectomy Gingivectomy by Chemosurgery

Gingivectomy means excision of the gingiva. By removing the pockt wall. Provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots. creates a favorable environment for gingival healing and restoration of a physiologic gingival contour.

INDICATIONS: 1. Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm. 2. Elimination of gingival enlargements. 3. Elimination of suprabony periodontal abscesses. 4. Increase the crown length.

Contraindications: 1- infrabony pocket. 2. Situations in which the bottom of the pocket is at or apical to the mucogingival junction. 3. Narrow or abscent attached gingiva. 4. The need for bone surgery or examination of the bone shape and morphology. (osseous surgery). 5. Esthetic considerations.

Types of gingivectomy: 1- Surgical Gingivectomy 2- Gingivectomy By Electrosurgery 3- Laser Gingivectomy 4- Gingivectomy By Chemosurgery

SURGICAL GINGIVECTOMY: Procedure: Local anaesthesia. Step 1: The pockets on each surface are explored with a periodontal probe and marked with a pocket marker to form a serious of small bleeding points. Each pocket is marked in several areas to outline its course on each surface.

Step 2: Periodontal knives used: A. Kirkland knives are used for incisions in facial and lingual surfaces. (external bevel incision)

Marking the depth of suprabony pocket. A, Pocket marker in position. B, Beveled incision extends apical to the perforation made by the pocket marker.

B. Orban periodontal knives are used for interdental incisions

How to make the incision? 1- The incision is started apical to the points marking the course of the pockets to a point between the base of the pocket and the crest of the bone.

2- It should be as close as possible to the bone without exposing it to remove the soft tissue coronal to the bone. 3- beveled at 45 degree to the root surface. (Failure to bevel leaves a broad, fibrous plateau that takes more time than is ordinarily required to develop a physiologic contour. In the interim, plaque and food accumulation may lead to recurrence of pockets.

4-it should recreate the normal festooned pattern of gingiva. 5- it should pass completely through the soft tissue to the tooth.

Types of incisions: Discontinuous incision: It started on facial surface at the distal angle of last tooth & forward to the next tooth (distofacial angle). Individual incisions are repeated for each tooth to be operated.

Continuous incision: It is started on the facial surface of the last tooth & carried forward without interruption, following the course of the pockets.

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.

After the first incision is made, Orban knife is placed in the incision & followed along the base of the pocket extending interproximally. Step 3: Remove the excised pocket wall, clean the area, and closely examine the root surface.

Step 4: Carefully curette out the granulation tissue and remove any remaining calculus and necrotic cementum so as to leave a smooth and clean surface. Step 5: Cover the area with a surgical pack

Healing after Surgical Gingivectomy: 1- the initial stage in healing after gingivectomy is the formation of a blood clot over the wound surface. the underlying tissue becomes acutely inflamed, with some necrosis. 2- By 24 hours, there is an increase in new connective tissue cells, mainly angioblasts, just beneath the surface layer of inflammation and necrosis

3- by the third day, numerous young fibroblasts are located in the area . The highly vascular granulation tissue grows coronally, creating a new free gingival margin and sulcus. 4- during the first 2 week after surgery, granulation tissue forms within the clot & the epithelium forms the wound edge & migrates over this granulation tissue.

5- from about 10 days to about day 30 there is organization of C 5- from about 10 days to about day 30 there is organization of C.T and keratinization of epithelium.

GINGIVECTOMY BY ELECTROSURGERY: Advantages: Electrosurgery permits an adequate contouring of the tissue and controls hemorrhage. Disadvantages: 1- cannot be used in patients with cardiac pacemakers. 2- unpleasant odor. 3- damage to the bone.

Indications: 1- gingival enlargements. 2- Gingivoplasty. 3- relocation of frenum and muscle attachments, and incision of periodontal 4- Incision of periodontal abscesses and pericoronal flaps

Contraindication: It should not be used for procedures that involve proximity to the bone, such as flap operations, or mucogingival surgery.

LASER GINGIVECTOMY: The CO2 laser beam has been used for the excision of gingival growths. healing is delayed when compared with healing after conventional scalpel gingivectomy. precautionary measures to avoid reflecting the beam on instrument surfaces, which could result in injury to neighboring tissues and the eyes of the operator. At present, the use of lasers for periodontal surgery is not supported by research

GINGIVECTOMY BY CHEMOSURGERY: Techniques to remove the gingiva using chemicals, such as 5% paraformaldehyde or potassium hydroxide, have been described in the past but are not currently used

Disadvantages: 1. The depth of action cannot be controlled, and therefore healthy attached tissue underlying the pocket may be injured. 2. Gingival remodeling cannot be accomplished effectively. 3. Epithelialization and reformation of the junctional epithelium and reestablishment of the alveolar crest fiber system are slower in chemically treated gingival wounds than in those produced by a scalpel

Gingivoplasty: is a reshaping of the gingiva to create physiologic gingival contours. Indications: Gingival clefts and craters, shelflike interdental papillae caused by acute necrotizing ulcerative gingivitis. may be done with a periodontal knife, a scalpel, or electrosurgery.

Excision of the soft wall of p.p Gingivectomy Gingivoplasty Excision of the soft wall of p.p It is performed to eleminate p.p It includes reshaping of the gingiva as a part of the technique. Reshaping the gingiva to create a normal function form. It is done with the sole purpose of recontouring the gingiva in the absence of p.p

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Describe the various modalities of Treatment of Gingival Enlargement Chronic Inflammatory Enlargement Periodontal and Gingival Abscesses Drug-Associated Gingival Enlargement Treatment Options Leukemic Gingival Enlargement Gingival Enlargement in Pregnancy Timing of Treatment and Indication Gingival Enlargement in Puberty Recurrence of Gingival Enlargement

Treatment of acute inflammatory enlargment 1- acute gingival abscess The lesion generally rupture spontanously If sever; vertical incision is done to relief pain & discharge pus ,no need for antibiotics 2- acute PDL abscess :Drainage can be established through the pocket or by means of an incision from the outer surface, antibiotics adminstration may be needed.

Chronic inflammatory enlargement Edematous tissue –treated with scalling ,oral hygene measures If extremely fibrous and interfer with access , surgical removal may indicated

Treatment of non-inflammatory enlargement 1- drug –induced phenytoin (Dilantin) Cyclosporin- A Calcium channel blocker (Nifidepine) Oral contraceptive pills 2-idiopathic gingival hyperpalsia

Prevention & treatment of drug induced gingival enlargement drug-associated gingival enlargement may be ameliorated, but not prevented,by elimination of local factors, plaque control and regular periodontal maintenance therapy. A 3-month interval for periodontal maintenance therapy has been recommended for patients taking drugs associated gingival enlargement. Each recall appointment should include detailed oral hygiene instructions and complete periodontal prophylaxis, with supra- and subgingival calculus removal as needed. In pediatric patients, it is recommended that parents also receive oral hygiene instructions. In some instances, orthodontic bands and/or appliances should be removed

treatment Drug substitution/withdrawal Treatment of phenytoin induced ginigval enlargement