GINGIVAL CURETTAGE AND GINGIVECTOMY Dr. OMAR ALHUNI Diplomate, American Board of Periodontology Residency specialty training in Periodontics Master of Sciences in Dentistry, Saint Louis University Bachelor of Dental Surgery, Garyounis University

Resective Surgery Soft Tissue Curettage ENAP Gingivectomy Hard Tissue Osseous Resection Regenerative Surgery GTR GBR

Curettage

It is a surgical procedure designed to remove the soft tissue lining of the periodontal pocket with a curet, leaving only a gingival connective tissue lining Rationale : to removes chronically inflamed granulation tissue that forms in the lateral wall ( inner surface) of the periodontal pocket it should always be preceded by scaling and root planning

Basic procedure: Local anesthesia The curette is selected so that the cutting edge will be against the tissue The pocket wall may be supported by gentle finger pressure Scooping motion of the curette to remove the inner lining of the pocket wall The area is flushed to remove debris The tissue is adapted to the tooth by gentle finger pressure

American Academy of Periodontology: The actual result obtained with curettage is most often a long junctional epithelium, which is the same result obtained with SRP alone. Short- and long-term clinical trials have confirmed that gingival curettage provides no additional benefit when compared to SRP alone in terms of probing depth reduction, attachment gain, or inflammation reduction. Dental community as a whole regards gingival curettage as a procedure with no clinical value.

Excisional New Attachment Procedure (ENAP) It is a definitive subgingival curettage performed with a knife Develop to accomplished proper tissue preparation Procedures: Internal bevel incision is made from the margin of the free gingiva apically to a point below the bottom of the pocket. Remove the excised tissue with a curette Root plane all exposed cementum Approximate the wound edges. Place sutures and a periodontal dressing. Gain better access to the root surface.

Gingivectomy

Gingivectomy Gingivoplasty The excision of a portion of the gingiva; usually performed to reduce the soft tissue wall of a periodontal pocket. Gingivoplasty Reshaping of the gingiva to produce a surface form and topography that simulates those features of gingival health

Gingivectomy/gingivoplasty indications: To eliminate gingival pockets (suprabony pockets) To create an esthetic gingival form in cases of delayed passive eruption To reduce gingival enlargements To create clinical crown length for restorative/endo

Contraindications: Acutely inflamed gingiva Inadequate oral hygiene PD that is apical to the MGJ inadequate keratinized gingiva Presence of infrabony defects Inadequate depth of the vestibule When removal of soft tissue would create an unacceptable cosmetic compromise

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

Surgical Gingivectomy

Healing after Surgical Gingivectomy Initial healing involves hemostasis and fibrin clot formation to cover the wound surface Cellular proliferation of epithelium at the wound margins Vascular proliferation (3-4 day peak) Epithelium begins to migrate across the CT surface after 2days until the wound surface is covered May take 1-2 weeks for complete surface epithelialization (no sooner than 5 days). By 14 days, the tissues assume a normal clinical form Some hypervascularity may persist (redness) Remodeling may continue for 3 months

Small front teeth Gingivecyomy procedure Full exposure of anatomic crown

GINGIVECTOMY BY ELECTROSURGERY: High frequency electric current is used to cut and coagulate soft tissue Brushing motion is used to remove incremental portions of soft tissue Best limited to superficial soft tissue procedures to avoid contact with bone or tooth root

Advantages: Disadvantages: Bloodless field Use in areas where application of knives is difficult / impossible. Disadvantages: Possible heat damage Increased time Unpleasant odor Cannot be used in pts with noncompatible or poorly shielded pacemakers May result in delayed healing, loss of attachment, and cemental burns.

Lasers gingivectomy CO2, Nd: Yag, and Diode (plus others…) Same limitations as electrosurgery Possible decreased post-op discomfort Possible delayed wound healing

Chemical gingivectomy Potassium hydroxide and Paraformaldenyde Not recommended Depth and action is difficult to control Reshaping of the tissues cannot be accurately accomplished Healthy tissues may be adversely affected Delayed wound healing

Drug induced gingival enlargement phenytoin (Dilantin) Cyclosporin- A Calcium channel blocker (Nifidepine Treatment: Drug substitution/withdrawal A 3-month interval for periodontal maintenance therapy

Which condition is a contraindication for the gingivectomy procedure? Stahl et al. (1971) noted complete epithelialization following gingivectomy in all specimens after _____ days. 7 14 21 28 During the process of healing after external bevel gingivectomy, surface epithelialization is complete no sooner than _____ days. 2 3 4 5 Which condition is a contraindication for the gingivectomy procedure? An adequate zone of attached gingiva Probing depths at or near the mucogingival junction Suprabony pockets Enlargement of interdental gingiva

Diplomate, American Board of Periodontology Dr. OMAR ALHUNI Diplomate, American Board of Periodontology Tel: 092-382-9123 Email: omar4huni@yahoo.com