Gingival Curettage / /certified fixed orthodontic courses by Indian dental academy

Curettage, Gingivoplasty & Gingivectomy

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com


Curettage
Contents

 what is curettage ?
Aim & Rationale
 Curettage & Esthetics
 Indications
Basic Technique
 Other Techniques
 Healing and appearance after curettage


Introduction


History

(Hirschfeld L Subgingival curettage in periodontal treatment. J Am

Dent Ass 1952; 44:301-314).


What is curettage ?

Curettage in periodontics means the scraping of the gingival wall of a

periodontal pocket to separate diseased soft tissue.

closed, definitive surgical procedure - pocket reduction, elimination,

reattachment, or new attachment.

Scaling and root planing may inadvertently

It is performed with sharp curettes in an attempt to remove (1) the

sulcular epithelium & epithelial attachment, & (2) the inflamed

connective tissue of the pocket wall


TYPES

Gingival curettage

Subgingival curettage

Inadvertent curettage


Aim & Rationale o f Curettage

Aim is to reduce pocket depth by enhancing gingival shrinkage, new
connective tissue attachment, or both.

Rationale

Therefore the need for curettage just to

eliminate the inflamed granulation

tissue appears questionable


Removal of granulation tissue

Flap surgery - technical rather
Curettage
than biologic reasons

Curettage in treatment of gingivitis ??

Reconstitution of a normal gingival plexus of bl.vessels in tissues ….
altered by chronic inflammation.

May not allow for normal metabolic interchange

Curettage …resolve ….optimal revascularization ….regenerated
gingiva
Not supported

(Loe, Theilade , Tensen – Experimental gingivitis in man JP: 36 : 177 :
1965 )


Curettage & Esthetics

Currently, esthetics is a major consideration of therapy

(anterior & requires preservation of the interdental papilla)

When regenerative therapy is not possible, every effort should be

made to minimize shrinkage - avoiding gingival curettage

Papilla Preservation Technique

Root planing apical to the base of the pocket - removal of the JE &

disruption of CT attachment.


INDICATIONS

As part of new attachment attempts

As a nondefinitive procedure to reduce inflammation prior to pocket

elimination & Compromised patients

Recall visits as a method of maintenance treatment for areas of

recurrent inflammation


Indications & Contraindications

Indications
1. Edematous and inflamed tissues
2. Shallow pockets
3. Suprabonypockets
4. As part of initial preparation prior to open surgical procedures in an
attempt to achieve tissue quality that can be handled easily
5. Progressive attachment or alveolar bone loss
6. Increased levels of pathogenic microorganisms
Contraindications
1. Fibrotic tissue
2. Deep pockets
3. Furcation involvements
4. Treatment of underlying osseous defects

Procedure for Curettage

Basic Technique
Does not eliminate the causes of inflammation
(i.e., bacterial plaque and deposits).- preceded by
SRP
Gingival curettage always requires some type of
local anesthesia.
The curette is selected so that the cutting edge will
be against the tissue (e.g., the Gracey No. 13-14 is
used for mesial surfaces and the Gracey No. 11-12
for distal surfaces).4R-4L Columbia Universal
curette
Engage the inner lining of the pocket wall -
horizontal stroke
Pocket wall - supported by gentle finger pressure
on the external surface.

In subgingival curettage, the tissues attached between the bottom of
pocket and alveolar crests are removed with a scooping motion of
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.


Other Techniques

1) Excisional new attachment procedure (ENAP)

2) Ultrasonic curettage

3)Chemical curettage

4 ) Laser curettage


Excisional New Attachment Procedure
(ENAP)

U.S. Naval Dental Corps
Yukna et al. (1976), ..attempt to overcome limitations of
closed gingival curettage & gain new attachment in areas of suprabony
pockets.
The E.N.A.P, unlike scaling and curettage, was developed to ensure
complete removal of sulcular epithelium, epithelial attachment,
granulated & inflamed connective tissue, subgingival calculus, &
softened
cementum.
Basically, it is curettage with a surgical blade, which increases access
& visibility with minimal tissue reflection.

ENAP
Indications
1. Suprabony pockets
2. Adequate keratinized tissue
3. When esthetics are unimportant

Advantages
1. Improved root visualization
2. Complete removal of sulcular epithelium & epithelial attachment
3. Minimal gingival trauma
4. No loss of keratinized gingiva


ENAP
Disadvantages
1. Difficult to determine apical extent of epithelial attachment
2. Does not result in new attachment

Contraindications
1. Pockets exceed Mucogingival junction
2. Edematous tissue
3. Lack of keratinized tissue
4. Osseous defects have to be treated
5. Hyper plastic tissue
6. Close root proximity
7. Furcation involvement

Technique – ENAP

Internal bevel incision

Remove the excised tissue with a
curette, & RP…preserve the ct

Approximate the wound edges


Modified E.N.A.P. Technique

DIAG

In 1977, Fredi and Rosenfeld modified the technique……

partial-thickness, inverse beveled incision down to the crest of the
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.

Ultrasonic Curettage.

Ultrasonic vibrations disrupt tissue continuity, lift off epithelium,
dismember collagen bundles, & alter the morphologic features of
fibroblast nuclei.

debriding the epithelial lining of pdl pockets - narrow band of necrotic
tissue (microcauterization), which strips off the inner lining of the
pocket.

The Morse scaler-shaped and rod-shaped instruments

Ultrasonic instruments to be as effective as manual instruments ……less
inflammation and less removal of underlying CT
(sanderson :curettage by hand & ultrasonics inst- a histologic comparison . JP 1966 : 37 :279 )

CHEMICAL CURETTAGE

Drugs such as sodium sulfide, alkaline sodium hypochlorite solution

(Antiformin), & phenol have been proposed & then discarded after
studies showed their ineffectivenes.

(Beube: Exp study of sodium sulphide sol in treatment of PDL pockets.
Texas Dent Jr 1953)

(Glickman : Effect of antiformin on soft tissue wall of PDL pockets .
JAMA 1955: 344)

The extent of tissue destruction …..cannot be controlled, may increase
rather than reduce the amount of tissue to be removed by enzymes and
phagocytes.

Laser curettage


Laser curettage

The goals …are epithelial removal, as with previous methods & in
addition, bacterial reduction.
A short-term study reported that Nd:YAG laser treatment did not produce
statistically significant bacterial reduction .(Radvar, Mc Farlane : An evaluation of
Nd:YAG laser treatment in PDL pocket therapy ; BDJ 1996 )

Confirmed in a multicenter study of laser curettage, which reported that
bacterial reduction was not often achieved. Only 1 of the 3 centers
reported a advantage in bacterial reduction over SRP alone. One pilot and
follow-p study did report bacterial reduction with a diode laser; however,
the laser treatment was repeated, while the SRP was not.
(Greenwell, Harris et al :Clinical evaluation of Nd:YAG laser curettage on periodontitis : JDR 1999 : Abs
2833 )
(Neill , Mellonig : Clinical efficacy of Nd:YAG laser for combination PDL therapy : Pract Periodontics

Aesthetics Dent 1997 : 9 : 1-5)

Laser ENAP

A recent commercial advertisement describes a "revolutionary . .
breakthrough in periodontal surgery that regenerates new attachment"
through the application of "a Laser ENAP procedure."
Despite FDA approval for sulcular debridement, the use of lasers for ENAP
and gingival curettage as proposed in the advertisement and several recent
journal articles should be evaluated in light of the available evidence.

Statement Regarding Use of Dental Lasers for
Excisional New Attachment Procedure (ENAP)

The Academy is not aware of any published data that indicates that the
ENAP laser procedure is any more effective for these purposes than
traditional scaling and planing.

To date, there are only four published human studies involving a total of 57
patients that have evaluated the effects of subgingival laser application.

All four papers report reductions in putative periodontal pathogenic
microbes following laser treatment. Two of the papers also reported laser
induced root damage. The remaining two papers did not evaluate treated
teeth for root damage.

In conclusion, The Academy is not aware of any randomized blinded
controlled longitudinal clinical trials, cohort or longitudinal studies, or
case-controlled studies indicating that "laser ENAP" or "laser
curettage" offers any advantageous clinical result not achieved by
traditional periodontal therapy.

Moreover, published studies suggest that use of lasers for ENAP
procedures and/or gingival curettage could render root surfaces and
adjacent alveolar bone incompatible with normal cell attachment and
healing.

(Millennium Dental Technologies, Inc. Dent Prod Report 1999;33 (May):40. Epstein SR. Curettage revisited: laser therapy.
Pract Periodontic Aesthet Dent 1992;4:27-32.
Gold SI, Vilardi MA. Pulsed laser beam effects on gingiva. J Clin Periodontol 1994;21:391-396.
Ben Hatit Y, Blum R, Severin C, Maquin M, Jabro MH. The effects of a pulsed Nd:YAG laser on subgingival bacterial flora
and on cementum: an in vivo study. J Clin Laser Med Surg 1996;14:137-143. )

Laser gingivectomy


HEALING AFTER SCALING AND CURETTAGE

Immediately after curettage - a blood clot

Hemorrhage ….polymorphonuclear leukocytes appear shortly

Rapid proliferation of granulation tissue

Restoration and epithelialization of the sulcus require 2 to 7 days

Restoration of the JE - 5 days after treatment.

Immature collagen fibers - 21 days.


CLINICAL APPEARANCE AFTER CURETTAGE

Immediately after curettage, the gingiva appears hemorrhagic and

bright red.

After 1 week, the gingiva appears reduced in height - apical shift in

the position of the gingival margin.

The gingiva is also slightly redder than normal

After 2 weeks - normal color, consistency, surface texture, and contour

of the gingiva are attained

The American Academy of Periodontology Statement
Regarding Gingival Curettage

The actual result ……..long JE, which is the same result with SRP alone.

The theoretical clinical advantage of curettage over SRP alone was

eliminated when new CT attachment was shown --unattainable goal.

Short- and long-term clinical trials have confirmed that gingival curettage

provides no additional benefit when compared to SRP alone in terms

of PD reduction, attachment gain, or inflammation reduction.


The American Academy of Periodontology Statement
Regarding Gingival Curettage

The consensus report of the Proceedings of the World Workshop in
Clinical Periodontics (1989) concluded : "Gingival curettage as a
separate procedure has no justifiable application during active therapy
for chronic adult periodontitis.

While gingival curettage is defined as being performed with a curet,
other methods have been reported. … same goal – no clinical or
microbial advantage – Chemical , Ultrasonic & Laser curettage


The American Academy of Periodontology
Statement Regarding Gingival Curettage

ADA has deleted the code from the fourth edition of Current Dental

Terminology (CDT-4).

In addition, the American Academy of Periodontology, in its

Guidelines for Periodontal Therapy did not include gingival curettage

as a method of treatment.

This indicates that the dental community as a whole regards gingival

curettage as a procedure with no clinical value.


Gingivectomy and Gingivoplasty


Contents

History
Definition & Rationale
Indications & Contraindications
Surgical Gingivectomy
Gingivoplasty
Healing after Surgical Gingivectomy
Gingivectomy by Electrosurgery
Healing after Electrosurgery
Gingivectomy by Chemosurgery
Laser Gingivectomy

Introduction

What happens if your teeth look too small,
too wide, too short or are not symmetrical
in size?

Do you have a "gummy smile"?


History

ROBICSEC (1884)

GRANT ET AL (1979) – Excision of the soft tissue wall of pathologic

periodontal pocket

ROBICSEC (1884) & ZENTLER (1918)

Stern IB; Everett FG; S. Robicsek - a pioneer in the surgical treatment

of periodontal disease. J Periodontol 1965; 36:265-268

Goldman HM The development of physiologic gingival contours by

gingivoplasty. Oral Surg Oral Med Oral Pathol 1950; 3:879-888

Definition

Gingivectomy is the Excisional removal of gingival tissue for pocket

reduction or elimination.

Gingivoplasty is the reshaping of the gingiva to attain a more

physiologic contour

Gingivectomy and gingivoplasty are usually
performed at the same time


Rationale
1. Pocket elimination for root accessibility
2. Establish physiologic gingival contours
Indications
1. Suprabony pockets
2. An adequate zone of keratinized tissue
3. Pockets greater than 3 mm
4. When bone loss is horizontal and no need exists for osseous surgery
5. Gingival enlargements
6. Areas of limited access
7. Unaesthetic or asymmetrical gingival topography
8. For exposure of soft-tissue impaction to enhance eruption
9. To facilitate restorative dentistry

Contraindications

1. An inadequate zone of keratinized tissue

2. Pockets that extend beyond the Mucogingival line

3. The need for osseous resection or inductive techniques

4. Highly inflamed or edematous tissue

5. Areas of esthetic compromise

6. Shallow palatal vaults and prominent external oblique ridges.

7. Treatment of intrabony pockets

8. Patients with poor oral hygiene

Advantages

1. Predictability

2. Simplicity

3. Ease of pocket elimination

4. Good access

5. Favorable esthetic results

Disadvantages

1. Healing by secondary intention

2. Bleeding postoperatively

3. Loss of keratinized gingiva

4. Inability to treat underlying osseous deformities

Gingivectomy Technique


Instruments

Local anesthetic syringes, needles & anesthetic solution
GoIdman-Fox periodontal scissors
Fox gingivoplasty diamond burs
Cotton surgical sponges
Periodontal mirror
Cotton pliers
Periodontal probe
Crane-Kaplan periodontal pocket markers
Kirkland 17 broad bladed GV knife
Orban sharp bladed GV knife
Columbia 4R 4Lor 2 R/2L curettes
Goldman-Fox tissue nippers
Minnesota surgical retractor
Surgical aspirator tip

Presurgical Phase

Reduce gross inflammation & remove local factors (calculus, plaque,

or overhanging restorations).

After initial healing, zone of attached tissue can be assessed properly.

Adequate local anesthesia is given. ….. vasoconstrictor.

Pockets are probed ..check depth and make sure they do not extend

beyond the Mucogingival junction

By sounding, the osseous topography is determined and the need for

osseous surgery determined

Pocket Marking


Incisions

Continuous or Discontinuous

Scalpel or GV knife

Bevel of 45


SURGIAL GINGIVECTOMY


Gingivectomy Incision


Ledge and Wedge & Internal Bevel
Gingivectomy Techniques


Gingivoplasty

Purpose is different.

Gingivectomy is performed to eliminate periodontal pockets and

includes reshaping as part of the technique.

Gingivoplasty is a reshaping of the gingiva to create physiologic

gingival contours, with the sole purpose of recontouring the gingiva in

the

absence of pockets.

Gingivoplasty may be done with a periodontal knife, a scalpel, rotary

Healing after Surgical Gingivectomy

Clot - granulation tissue.
By 24 hours, there is an increase in new connective tissue
The highly vascular granulation tissue grows coronally, creating a
new free gingival margin and sulcus. Capillaries ..and within 2 weeks
the connect with gingival vessels .
After 12 to 24 hours, epithelial cells at the margins of the wound start to
migrate over the granulation tissue
Epithelial activity at the margins reaches a peak in 24 to 36 hours.The epithelial
cells advance by a tumbling action, with the cells becoming fixed to the
substrate by hemidesmosomes and a new basement lamina
Surface epithelization is generally complete after 5 to 14 days.


During first 4 weeks after gingivectomy, keratinization is less than it

was prior to surgery.

Complete epithelial repair takes about 1 month. Vasodilation and
vascularity begin to decrease

Complete repair of the connective tissue takes about 7 weeks. gingival
fluid in humans is initially increased after gingivectomy & diminishes
as healing progresses.

Maximal flow is reached after 1 week

Postgingivectomy healing are the same in all individuals, the time

required for complete healing varies depending on the area of the cut

surface and interference from local irritation and infection.


Gingivectomy by Electrosurgery

Advantages

Electrosurgery permits an adequate contouring of the tissue

and controls hemorrhage

Disadvantages

Noncompatible or poorly shielded cardiac pacemakers.

Unpleasant odor.

If the electrosurgery point touches the bone, irreparable damage can be
done

Cementum burn.

Therefore the use o f electrosurgery should be limited to superficial

procedures such as removal of gingival enlargements, gingivoplasty,

relocation of frenum and muscle attachments, and incision of

periodontal abscesses and pericoronal flaps; extreme care should be

exercised to avoid contacting the tooth surface.

It should not be used for procedures that involve proximity to the

bonesuch as flap operations, or mucogingival surgery.


Technique

The removal of gingival enlargements and
gingivoplasty is performed with the needle
electrode, supplemented by the small ovoid loop or
the diamond-shaped electrodes for festooning. A
blended cutting and coagulating (fully rectified)
current is used.

In all reshaping procedures, the electrode is
activated and moved in a concise "shaving" motion.

For hemostasis, the ball electrode is used.

Electrosurgery is helpful for the control of isolated
bleeding points. Bleeding areas located
interproximally are reached with a thin, bar shaped

Healing after Electrosurgery

Some investigators report no significant differences in gingival healing
after resection by electrosurgery and resection with periodontal knives;
other researchers find delayed healing, greater reduction in gingival

height, and more bone injury after electrosurgery.

There appears to be little difference in the results obtained after
shallow gingival resection with electrosurgery and that with
periodontal knives. However, when used for deep resections close to
bone, electrosurgery can produce gingival recession, bone necrosis
and sequestration, loss o f bone height, furcation exposure, and tooth
mobility, which do not occur with the use of periodontal knives


Laser Gingivectomy


Laser Gingivectomy

The lasers most commonly are (CO2) and (Nd:YAG), which have
wavelengths of 10,600 nm &1064 nm, respectively, both in the infrared
range

The CO2 laser beam has been used for the excision of gingival growths,

although healing is delayed when compared with healing after
conventional scalpel gingivectomy.

The use of laser beam for oral surgery requires 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

The Use of the CO2 Laser for the Removal of Phenytoin Hyperplasia
Robert M. Pick,Bernard JP 1985 Aug (492 - 496):
Twelve cases using the CO2 surgical laser for the removal of phenytoin
(Dilantin) hyperplasia have been performed

Surgical Treatment of Cyclosporine A- and Nifedipine-Induced
Gingival Enlargement: Gingivectomy Versus Periodontal Flap.
JP1998 : 69 : 791(Andrea Pilloni, Paulo M. Camargo, Mauro Carere,
and Fermin A. Carranza, Jr.)

An evaluation of ND ; YAG laser to improve clinical and
microbiological paraeters of periodontal disease ( BDJ : 1996 )


Gingivectomy by Chemosurgery

5% paraformaldehyde or potassium hydroxide

They are presented here to provide a historical perspective.

Disadvantages:

1. The depth of action cannot be controlled

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.
The use of chemical methods therefore is not recommended.

References

Clinical Periodontology – Carranza - 9 Th Edition

Clinical Periodontology And Implant Surgery – Jan Lindhe
- 4th Edition.

Position Papers – American Academy of Periodontology

Periodontology & Periodontics : Sigurd P Ramfjord

Periodontics : Louise Rose , Brian Mealey

Periodontal Therapy – Clinical Approaches And Evidence Of
Success – James Mellonig & Myron Nevins

Guide To Periodontics-2 Edition – W W M Jenkins

Net references

Gingival Curettage / /certified fixed orthodontic courses by Indian dental academy

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