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Lecturer: Levkiv Mariana O.
Department of Therapeutic Dentistry
TSMU
Periodontal therapy is directed at disease prevention,
slowing or arresting disease progression, regenerating lost of
periodontium, and maintaining achieved therapeutic objectives.
A variety of different treatment techniques have been used
including subgingival curettage, gingivectomy, modiﬁed
Widman ﬂap, and full- or split-thickness ﬂap procedures
with or without osseous recontouring. The best surgical
approach remains controversial, although the results of
longitudinal clinical trials has highlighted the advantages and
disadvantages of each technique.
Curettage, scaling and root planing and modiﬁed Widman ﬂap
produced slightly better attachment level results, while pocket
elimination procedures gave the greatest probing depth
reduction.
Surgical techniques included: gingivectomy, modiﬁed Widman
ﬂap with and without osseous recontouring, and apically
positioned ﬂap with and without osseous recontouring. All
techniques halted loss of attachment, but the greatest gain of
attachment was achieved when osseous resection was avoided
and soft tissue was sutured to completely cover alveolar bone.
No study to date has shown that plaque is the cause of
periodontitis, but these studies certainly demonstrated that
with no plaque there is no disease progression.
Indications for periodontal surgery
Nonsurgical therapy is performed prior to surgical treatment for
periodontitis. Surgery is indicated where nonsurgical methods fail.
In general, the success of nonsurgical treatment should be
assessed following scaling and root planing but prior to the
administration of antimicrobial agents or antibiotics.
These medications tend to reduce inﬂammation and obscure sites
where scaling and root planing has failed to resolve disease.
Pocket reduction or elimination is not required in sites that
respond to nonsurgical therapy and remain stable during
maintenance. When surgery is required, however, shallower
probing depths may be an appropriate goal to facilitate
maintenance therapy and reduce the incidence of recurrence.
* Improved visualization of the root surface;
* More accurate determination of prognosis;
* Improved pocket reduction or elimination;
* Improved regeneration of lost periodontal
structures;
* An improved environment for restorative
dentistry;
* Improved access for oral hygiene and supportive
periodontal treatment.
This procedure is used to excise suprabony pockets if there is sufﬁcient
attached gingiva, to reduce gingival overgrowth/hyperplasia, and for
aesthetic crown lengthening in certain situations. Generally, this procedure
should not be used when:
1)
Infrabony pockets/defects are present;
2)
osseous surgery is required;
3)
there is inadequate attached gingiva;
4)
frena/muscle attachments interfere;
5)
and long clinical crowns will compromise aesthetics.
A gingivectomy and gingivoplasty was used to correct
gingival aberrations
A. Preoperative. B. Gingivectomy based upon aesthetic proﬁle ratio.
C. Gingivoplasty.
D. 8 weeks postsurgically.
*
* The word curettage is used in periodontics to mean scraping
of the gingival wall of a periodontal pocket to remove
inflamed soft tissues.
* Curettage removes the soft tissue lining of the periodontal
pockets in order to completely eliminate bacteria and
diseased tissue. It may be used along with scaling and root
planing, but achieves a deeper and more complete
cleaning. Evidence indicates, however, that it does not
contribute any additional benefits beyond simple scaling
and planing.
* Inadvertant curettage:Some degree of curettage done
unintentionally when scaling and root planing is performed.
Presurgical curettage: used in patients whose treatment plans
include strong evidence that a surgical phase will be used.
Definitive curettage: No other therapy will be required or used.
Gracey Curettes: Used for eliminating
the Soft Tissue Wall of the
Periodontal Pocket
RATIONALE
Accomplishes removal of chronically inflamed granulation tissue
in the lateral wall of periodontal pocket.
Apart from the usual components of angioblastic and fibroblastic
proliferation in granulation tissue, may also contain pieces of
dislodged calculus and bacterial colonies.
INDICATIONS
* Curettage can be performed in moderately deep infrabony
pockets located in accessible areas where a type of ‘closed
surgery’ is deemed advisable.
* Done to reduce inflammation prior to pocket elimination using
other methods or in patients in whom surgical techniques are
contraindicated
* Shrinkage of localized areas of gingiva, particularly interdental
papillae which are bulbous and lead to plaque retention and
accumulation
* Curettage is frequently performed on recall visits as a method of
maintenance treatment for areas of recurrent infection.
CONTRAINDICATIONS
* Presence of acute infection
* Fibrous epithelial enlargement of gingiva as in phenytoin
hyperplasia
* Frenal pull on gingival margin
* Extension of base of pocket apical to mucogingival junction.
PROCEDURE
* Basic technique-curette is selected so that the cutting edge
will be against the tissue.
* Instrument is inserted so as to engage the inner lining of
pocket wall and is carried along the soft tissue
* Pocket wall maybe supported by gentle finger pressure on
the external surface.
OTHER TECHNIQUES
Excisional new attachment
procedure(ENAP): Definitive
subgingival curettage procedure.
ENAP was an attempt to overcome
some of the limitations of closed
gingival curettage.
Ultrasonic curettage
Ultrasonic vibrations disrupt tissue
continuity, lift off epithelium and
dismember collagen bundles.
Effective for debriding the epithelial
lining of periodontal pockets.
It results in a narrow band of
necrotic tissue(microcauterisation)
which strips off the inner lining of
the pocket
Also it is recommended while conducting closed curettage, to
rinse the periodontal pocket with antiseptic solutions. Such
procedure is called “one-time curettage”. Antiseptics that
can be used:Chlorhecsidine 0,2%, peroxide hydrogeny 0,3%,
Chloramini 0,5%.
* Caustic Drugs: To induce a chemical curettage of the
lateral wall of the pocket
* Drugs such as sodium sulfide, alkaline sodium hypochlorite
solution(antiformin) and phenol were used.
* The extent of tissue destruction with these drugs cannot
be controlled and they may be increase rather than
reduce the amount of tissue to be removed by enzymes
and phagocytes.
* LASERS – Laser curettage in suprabony pockets where
osseous surgery is not required.
* When performed with mechanical root instrumentation, it
is considerably less invasive than traditional flap surgery.
* Due to small size of fiber(ie)tip diameter,Nd:YAG laser has
been suggested as a good candidate for gingival
curettage.
TISSUE RESPONSE TO CURETTAGE
* Reversal of all signs of gingival inflammation.
* Shrinkage, resolution of oedema and exudation.
* Morphologic features in gingiva and mucosa are delineated
more clearly after inflammation has been resolved.
* Exuberant granulation tissue rarely present postoperatively.
* Gingiva is firm to the scalpel and is of good texture to be
beveled or split as required.
HEALING AFTER CURETTAGE
* Blood clot fills the gingival sulcus which is totally or
partially devoid of epithelal
lining.
* Hemorrhage present in tissues, abundant PMNL’s apper
shortly on wound surface.
* Restoration and epithelialisation of sulcus generally
requires from 2-7days.
* Immature collagen fibres appear in 21days.
* Zander and Waerhaug et al reported that resulted in
formation of long junctional epithileum.
CLINICAL APPEARANCE
* Gingiva appears haemorrhage and bright red.
* After 1 week, gingiva appears reduced in height owing to an apical
shift in positon of gingival margin
* After 2 weeks,with proper oral hygiene by patient, normal
consistency and color of gingiva are attained and gingival margin well
adapted to the tooth.
* GINGIVAL CURETTAGE – RELEVANCE
* Gingival curettage and debridement of soft tissue wall of the pocket
as an adjunct to SRP seems to offer no advantage in the initial
healing response over SRP alone.
* Removal vs non removal of granulation tissue during flap surgery and
non surgical therapy (SRP) was studied by Lindhe & Nyman (1985).
There results failed to show an advantage of granulation tissue
removal.
* Studies provide
convincing evidence that SRP alone produce results
clinically equivalent to curettage plus SRP.
* The various methods used for epithelial removal show that
they have no advantage over mechanical instrumentation
with curette.
* Therefore gingival curettage by whatever method performed
should be considered as a procedure that has no additional
benefit to SRP alone in treatment of chronic periodontitis.
Comparison between the results obtained in the initial
preparation of the periodontal treatment such as oral
hygiene and scaling and root planing and that of same
procedure supplement by curettage, are made to assess the
justification of using curettage to eliminate gingival
inflammation and accomplish retraction of the gingiva.
One-time curettage: X-ray study
Due to the histological and clinical healing response
investigated by current studies, the advantages of curettage in
the shallow pocket are debatable. Curettage are now to be
done in deep pocket, especially in the aggressive lesion such as
that of the localized junvenile periodontitis. Nevertheless,
there is insignificant difference between the result of the
scaling and root planing alone and scaling and root planing
with the tissue curettage.
One-time curettage: X-ray study
This procedure, introduced by Ramfjord & Nissle, was designed
to remove the inﬂamed pocket wall, provide access for root
debridement, and preserve the maximum amount of
periodontal tissue. It is indicated where aesthetics is a primary
concern, especially in the maxillary anterior sextant. The
drawbacks include the inability to achieve pocket elimination
and healing with a long junctional epithelium. (Open
curettage)
After completing scalloped section, parallel to the
gingival margin, and additional sections, partly
movable muco-periosteal flap is shifted to the level of
the alveolar ridge.
Treatment of the teeth roots is carried out under
visual control by curettes or ultrasonic instruments.
Then the flap is adapted to the underlying tissues and
stitched in the interdental spaces.
A modiﬁed Widman ﬂap was used to reduce periodontal pockets around
teeth # 12–15 (buccal and palatal view)
A, B. Preoperative.
C, D. Incision
E, F. Flap reﬂection.
G, H. Suture.
I, J. 1 week of healing.
K, L. 8 weeks’ follow-up.
Histological studies have shown the ﬂap procedures described
above tend to heal with a long junctional epithelium and not a
new connective tissue attachment. Long junctional epithelium,
however, has been shown to provide a stable therapeutic
outcome.
Historically the aims of periodontal surgery were to remove the
soft tissue pocket wall and infected bone and to eliminate the
periodontal pocket.
Currently, the goals of surgery are to: 1) gain access for root
preparation when nonsurgical methods are ineffective; 2)
establish favorable gingival contours; 3) facilitate oral hygiene;
4) lengthen the clinical crown to facilitating adequate
restorative procedures; and 5) regain lost periodontium using
regenerative approaches.
To ensure proper healing atraumatic surgical principles should
be followed including: 1) adequate anesthesia; 2) surface
disinfection; 3) sharp instrumentation; 4) minimal, atraumatic
tissue handling; 5) short operating time; 6) preventing
unnecessary contamination; and 7) proper suturing and dressing,
if indicated.
Flap operations
The formation of the flap and the types of sections
Throwing soft tissue flap starts with the precise cuts. The
location and direction of the cuts depends on the type of
periodontal defect, purpose of surgical intervention and
the desired result.
The horizontal incision is made in all cases. it
can be intrasulcular (within the gingival sulcus) or
paramarginal (parallel to the gingival margin, at some
distance from it). In paramarginal section, connecting
epithelium is excised, and gingival margin shifted in the
apical direction. In this type of incision is the so-called
latent gingivectomy. When viewed from the vestibular or
lingual side, the paramarginal section has scalloped
shape, close to the ideal form of the gingival margin.
If it is a wide interdental spaces, it is recommended a special
flap that preserves gingival papillae (Takei et al, 1985). There
is also a modification of this flap for narrow interdental spaces
(Cortellini et al., 1995).
Vertical sections are not always necessary or desirable,
because they lead to the appearance of scars on the mucous
membrane. If a vertical incision is required, it should be done
in order to prevent gingival recession or loss of interdental
papilla.
A.
B.
C.
Horizontal sections
traditional horizontal sections are performed from
vestibular (red line) and the oral side (blue line). In
interdental spaces, the surface of the tissue sections are
arranged parallel or diagonally.
Intrasulcular section at which epithelium of the pocket is
not excised, but the maximum amount of soft tissue is
saved.
Paramarginal sections is performed at different
distance from the gingival edge. Part of the tissue is
excised by means of gingivectomy.
The flap that preserves the
gingival papillae.
When suturing the wound after the operation, the soft tissue
cover interdental spaces. However, this flap can be formed
only at relatively wide interdental gaps.
D. Papilla are displaced in the vestibular direction during the
flap formation.
E. Papilla are displaced in the oral direction.
Vertical sections and
relaxing sections
Unfavorable location:
A.
If the cut goes through
the papilla, there is risk
of recession and loss of
interdental papilla.
B.
The middle section is
undesirable
in the presence of
vestibular pocket, as it
increases the probability
of gum recession.
The favorable location:
C. The section at the side of
midline does not
leads to significant shrinkage
and is better for healing.
D. For the treatment of local
defects it is
recommended a triangular
flap, to unfold it ,
two paramedial sections is
conducted.
* Guided Tissue Regeneration. A more advanced technique,
called guided tissue regeneration, is used to stimulate
bone and gum tissue growth:
* First, the root surfaces and diseased bone are meticulously
cleaned out. Preventing bacterial contamination is very
important. The more residual bacteria, the greater the
chance that the treatment will fail.
* A specialized piece of fabric is sewn around the tooth to
cover the crater in the bone left after the cleaning. It is
either absorbable or nonabsorbable. (Some studies report
highly beneficial results with new absorbable materials,
including those coated with the antibiotic doxycycline.)
* Bone Grafting. In some cases of severe bone loss, the surgeon may
attempt to encourage regrowth and restoration of bone tissue that
has been lost through the disease process. This involves bone
grafting:
* The surgeon places bone graft material into the defect.
* The material may be either bone from the same patient or a
substance called decalcified freeze-dried bone allografts (DFDBA)
which is obtained from a donor.
* This material then stimulates new bone growth in the area.
* Enamel Matrix Protein Derivative. Amelogenin is a derivative of a
major protein in the structure (the matrix) of enamel that helps
stimulate gum tissue growth. A gel containing amelogenin
(Emdogain) is applied during surgery and forms a coat over the
roots of the teeth. The gel itself dissolves after 2 days, leaving the
active substance behind. Studies report that it is safe and may
significantly reduce the effects of periodontal disease. A 2001
study suggested that the benefits, as indicated by bone
attachment, can persist for at least 4 years. (Results were similar
to guided tissue regeneration.)
The risks of surgery include pain, swelling, blood loss, reaction
to medications, and infection. Other potential risks include root
sensitivity, ﬂap sloughing, root resorption or ankylosis, some
loss of alveolar crest, ﬂap perforation, abscess formation, and
irregular gingival contours. If post-operative complications
occur, they should be managed by prompt and appropriate
treatment, which may include control of bleeding, adequate
analgesics or antibiotics.
Post-surgery discomfort is usually managed easily with overthe-counter medications such as ibuprofen. If discomfort is
severe, stronger analgesics may be prescribed. Some patients
experience sensitivity to hot or cold temperatures from
exposed roots. These problems can be managed with topical
fluoride treatments or, in severe cases, with dental restoration.
*