Minor Periodontal Surgical

Procedures
Seminar by:

Aparna S

Introduction

Contents :
Rationale Minor procedures : Curettage Gingivectomy Crown Lengthening Operculectomy

Frenotomy/ frenectomy
Vestibular deepening procedures Depigmentation Conclusion

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 facilitate adequate restorative procedures; and 5) Regain lost periodontium using regenerative approaches.

* Hom Lay Wang , Henry Greenwell perio 2000, 2001

Curettage :
Scraping of the gingival wall of a periodontal pocket to separate diseased soft tissue.
Gingival Curettage : removal of inflamed soft tissue lateral to the pocket wall

Subgingival curettage : is the procedure that performed apical to the epithelial attachment,

severing the connective tissue attachment down to the osseous crest.

Inadvertant curettage : spontaneous removal of the pocket lining during scaling and root planing.

Indications :
Part of new attachment procedures in moderately deep intrabony pockets closed surgery Reduce inflammation pocket elimination surgeries Recall visits Patients aggressive surgical techniques contraindicated

Rationale :
Removes chronically inflammed granulation tissue - fibroblastic and angioblastic

proliferation , calculus deposits , areas of inflammation

Lined by deep strands of epithelium barrier to attachment of new fibres

Root planing : removal of bacteria

resolution of pathologic changes

Existing granulation ts slowly absorbed , bacteria destroyed by host defense

Eliminate inflammed granulation tissue ?????

 Carranza 1954, Hirschfield 1952 : Curettage new attachment Caton j et al 1980 : SRP , Curettage long junctional epithelium Gingival curettage : closed surgical procedure no access to roots Ainsle et al , Caffesse et al 1981 , Caffesse RG et al 1983 , Ramjford et al 1981 Gingival curretage no additional benefit over SRP in terms of PD reduction, attachement gain or inflammation reduction .

AAP report 2002 : Comparing SRP alone to curettage plus SRP, it was concluded that curettage did not serve any additional useful purpose. no justifiable application during active therapy for chronic adult periodontitis.

Technique :

Other Techniques :
1. ENAP : US Naval Dental Corps 1975, Yukna et al 1976 definitive subgingival curettage procedure

Advantages : 1. Avoid flap reflection, pocket removed 2. Knife edge 3. Allows for debridement

2. Ultrasonic Curettage : (Nadler 1962 )

- Vibrations disrupt tissue continuity, lift off epithelium, dismember collagen bundles alter morphologic features of fibroblast nuclei Goldman 1961

- effective for debriding the epithelial lining of pd pckt. resulting in a narrow band of
of necrotic tissue which strips off the inner lining

3. Caustic agents : Stewart H (1899)

- Induce chemical curettage of lateral wall of pocket - Sodium sulfide, alk. Sod hypochlorite solution ( Antiformin) - Antiformin : coagulates the soft tissues removal of inflammed tissue Disadv : extent of destruction not controlled.

Healing after curettage :

Blood clot PMNs granulation ts epith 2-5days

Immature collagen fibres 21 days

Moskow et al , Waerhaug et al LJE Caton JC et al : windows of ct attachment

Clinical appearance : Immediately after 1 week after 2 weeks

Gingivectomy :
Introduced by Robicsek in 1884 , described by Grant et al 1987

Resect / excise the soft tissue wall of the pocket POCKET ELIMINATION
Gingivoplasty : recontour gingiva that has lost its physiologic outer form

Rationale :

Removes the diseased pocket wall that obscures the tooth surface

visibility and accessibility for complete removal of surface deposits and planing of roots

Favourable environment for gingival healing restoration of physiologic gingival contour

Technique :
Goldman 1951

Prerequisites :
1. Reduced inflammation 2. Functionally adequate zone of attached that must exist apical to the base of the gingival pocket

Indications : Glickman 1956 :

1. 2. 3. Eliminate gingival / suprabony pockets Eliminate gingival enlargements Eliminate suprabony periodontal abcesses

Clarke :
1. Eliminate gingival pockets

2.

Create aesthetic tooth form & gingival symmetry in cases of delayed passive eruption
and gingival enlargement

3. 4. 5.

Transform rolled/ blunted margins to ideal physiologic form Correct soft tissue craters Gain additional crown length for restorative , endodontic & /or prosthetic purposes

Contraindications :
Hyperemia and edema of tissues

Pocket extends beyond the MGJ

Functionally inadequate gingiva Interdental / osseous infrabony craters, defects Thick buccal / lingual ledges , exostoses Short / shallow palatal vault

Ledge and Wedge approach : Oschenbien 1965

Objective : remove all gingiva coronal to the bottom of the gingival sulcus Technique :

Gingivoplasty:
No pocket elimination

Recontour gingiva
Gingival clefts, craters , shelf like interdental papillae caused by ANUG, gigival enlargement Incision : similar to gingivectomy Taper the gingiva, create scalloped outline, thin attached gingiva, create vertical interdental grooves shape interdental papillae to provide sluiceways

Healing after gingivectomy :

Surface clot (mins ) within 12hrs , necrotic debris and monolayer of PMNs

24hrs ct cells , angioblasts 3rd day fibroblastic proliferation Persson et al 1959 2wks capillaries from bv s of pdl Epith complete 5 14 days migrate into the granulation ts connect with gingival vessels

 Stanton et al 1969 complete epithelialization takes about 1 month Complete repair 7 weeks Other methods : - Chemical method : 5 % paraformaldehyde (Orban 1942) , Pot. Hydroxide (Loe H ) disadv : excessive tissue injury - gingival remodeling no effective - epith & reformation of JE and reestablishment of the alv.crest fibres occur more slowly (Tonna et al 1967 ) - Electrosurgery

Electrosurgery :
Adv : permits contouring of ts and control hemorrhage

Disadv : noncompatible/ poorly shielded cardiac pacemakers

unpleasant odour
heat generated tissue damage , loss of pd support touches root areas of cementum burn

Uses : gingival enlargements , gingivoplasty, relocation of frenum

& muscle attachments , incision of pd.abscesses, pericoronal flaps Technique : needle electrode + small ovoid loop / diamond shaped electrodes for festooning - shaving gentle motions : fully rectified current

Healing after electrosurgery :

Fisher et al 1983, Malone et al 1969 : no difference btw scalpel , electrosurgery

Pope et al 1968 : difference delayed healing , greater reduction in gingival height ,

more bone injury

Glickman & Imber : gingival recession , bone necrosis & sequestration , loss of bone ht, furcation exposure , tooth mobility

Frenectomy / frenotomy :
Frenum : band of fibrous tissue covered with mucosa extending from the lip , tongue &

cheek to the alveolar periosteum

-Types of frenal attachments

-Effects ? - Indications - if adequate gingiva is present coronal to the frenum , no need to remove it surgically

Frenotomy : relocating frenal attachment to create a zone of attached gingiva btw gingival margin & frenum Frenectomy : excising the frenum , including its attachment to bone

Rationale : frenum that encroaches on the margin of the gingiva interfere with
plaque removal, increase rate of periodontal recession and recurrence after treatment

Other Techniques :

Edward s Technique :

Z plasty :
Thick fibrous frenum

Adv : may decrease amt of vestibular ablation sometimes seen after linear excision of a frenum

Frenotomy with vestibuloplasty

When the base of the frenum is wide

Mandibular anterior frenal attachments

Lingual frenectomy :
Tongue tie

Affects speech , movements of the tongue Close to vital structures Careful surgical procedure

Frenectomy / frenotomy - Orthodontic treatment

Early studies frenectomy prior to orthodontic treatment cause for diastema Now : delayed surgical treatment permanent teeth erupt difficulty in moving teeth through scar tissue & self correcting nature Edwards JG 1977 : 77% reduction in opening of diastema when frenectomy after orthodontic treatment

Miller 1985
Frenectomy interdental papilla undisturbed.

A pedicle graft laterally positioned across the midline to obtain primary closure gingiva across the midline ; not scar tissue. Gingivoplasty labially or palatally to remove any excessive tissue. Objective : obtain orthodontic stability without compromising the aesthetics

Miller PD. The frenectomy combined with a laterally positioned pedicle

graft. Functional and aesthetic considerations. J Periodontol l985: 56: 102-106.

Electrosurgery for abberrant frenum :

Loop electrode Stretch the frenum/ muscle section with coagulating current

Vestibular deepening procedures :

Shallow vestibule difficulty in brushing plaque accumulation

mucosal injury Edlan and Mejchar (1963) widening of attached non keratinized gingiva Bohannan 1962 : long term results unsuccessful (non graft procedures)

Other techniques :
1. 2. 3. Kazanjian s Lip switch technique (Transpositional Flap Vestibuloplasty) Obwegeser s technique Clark s technique

Operculectomy :
Acute pericoronitis - severity of inflammation

Persistent symptom free flaps prevent infection When? Eruption of tooth in arch

Bone loss distal to 2nd molar

Extract or retain?? If retained : pericoronal flap removed

Crown lengthening procedures :

Short clinical crowns : unaesthetic , inadequate for retention of restorations Methods to increase crown length : surgically gingivectomy

Flap surgery with osteotomy/ osteoctomy

Orthodontic extrusion . Biologic width : dimension of space that healthy gingival tissues occupy above the alveolar

bone

Garguilo , Wentz, Orban 1961

Variations exist : Vacek et al 1994 : BW patient specific Range of 0.75mm 4.3mm Aleast 3mm of sound tooth str above

the alveolar crest

-If gingiva thick with adequate att gingiva gingivectomy -Otherwise apically repositioned flap with osseous resection If margin of restoration subgingival : atleast 3mm equigingival : atleast 4mm

Why ? To diagnose BW violation when restorative margin is placed 2mm or less away from the alveolar bone and the gingival tissues are inflammed with no other etiologic factors evident.

Restorations : supragingival, equigingival or subgingival Subgingival : create adequate resistance and retentive form

caries / tooth deficiencies

mask the tooth- restn margin

Body s response :

Evaluation :
Evaluate clinically caries, amt of residual tooth structure,

Evaluate the gingival morphology- post treatment

gingival margins Radiographs

Probing under LA
- BW : marginal gingiva to bone sulcus depth

Objectives :
l. Removal of subgingival caries

2. Enabling restorative treatment without impinging on

biologic width 3. Correction of occlusal plane

4.Facilitation of improved oral hygiene

5. Cosmetic improvement

Diagnostic considerations include:

l. Subgingival caries and the degree of extension of the clinical crown fracture apically 2. Whether the clinical crown/root ratio after restorative treatment may be unfavorable

3. Root length and root morphology

4. Residual amount of supporting bone after crown lengthening (especially osseous resection)

5. The degree of periodontal support lost from the adjacent tooth 6. The possibility of furcation exposure as well as unfavorable exposure of root surface (including grooves), which may complicate maintenance 7. Increasing tooth mobility due to diminished supporting tissue and

its influence on occlusion

8. Whether proper plaque control can be maintained after the placement

Procedures :
1. Simple Crown Lengthening - esthetic crown lengthening - short crowns, different gingival margins - gingivectomy/ recountouring

2. Compound crown lengthening : functional lengthening

Lasers The New Scalpel????

Lasers Nd:YAG, CO2 , Er: YAG soft tissue procedures

FDA clearance 1976

Pick RM et al 1985 CO2 laser gingivectomy CO2 laser gingivectomy , gingivoplasty, frenectomy, adjunct to non surgical & surgical procedures Nd: YAG laser , diode laser Aoki et al 1994 , Schwarz et al 2001, Walsh 2003, Haytac et al 2006,

Nd: YAG laser : soft tissue curettage Radvar et al 1996 no statistically significant bacterial reductn Diode laser : Moritz et al 1997 , 98 : repeated application of laser for curettage in comparision with SRP Haytac et al 2006 : frenectomy with CO2 laser reduction in patient perception of pain, hemostasis Cobb 2006 : No evidence to show that lasers are superior to SRP or advantageous over scalpel in soft tissue procedures. Hemostasis and post op discomfort less, healing delayed (AAP Review)

Depigmentation
Melanin, bilirubin, iron, metals bismuth, amalgam etc..

Physiologic / pathologic Rationale : aesthetics!!! Criteria for case selection : - disparity btw skin tone & gingival colour - healthy periodontium - adequate thickness of the tissues Techniques chemical , cryosurgery, surgical , electrosurgery, lasers

- Gingivoabrasion
- Split thickness epithelial excision - Combination

Depigmentation

Depigmentation Lasers :
Non specific beam laser ablate melanocytes Er:YAG laser 500 mJ pulsed * Radiation energy Min heating of tissues ablation energy cellular rupture & vaporization

* Tal H et al 2003 Gingival depigmentation by Er:YAG laser: clinical observations

and patient responses.

Conclusion

References :
1. Caranza 8 th, 9th ed, 10th edition 2. Lindhe 4th ed 3. Clarke Clinical dentistry : Periodontal and Oral surgery 3rd ed 4. Peterson Oral and Maxillofacial Surgery

5. Sato Clinical Atlas

6. Ratnadeep Patil Aesthetic Dentistry 7. Perio 2000 2004, 2001, 1995, 1996

8. JP2006,JP2002,
9. Net References

Courage is not always a roar. Sometimes its a quite voice at the end of the day saying I will try again tomorrow.

Thank you.
Have a good weekend !