Minor Periodontal SurgicalProcedures Seminar by: Aparna S Introduction Contents : Rationale Minor procedures : Curettage Gingivectomy Crown Lengthening Operculectomy Frenotomy/ frenectomy Vestibular deepening procedures Depigmentation Conclusion 2001 . * Hom – Lay Wang . Henry Greenwell perio 2000.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. Curettage : Scraping of the gingival wall of a periodontal pocket to separate diseased soft tissue. Inadvertant curettage : spontaneous removal of the pocket lining during scaling and root planing. severing the connective tissue attachment down to the osseous crest. . Gingival Curettage : removal of inflamed soft tissue lateral to the pocket wall Subgingival curettage : is the procedure that performed apical to the epithelial attachment. 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 . bacteria destroyed by host defense Eliminate 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 .Rationale : Removes chronically 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 Sodium sulfide.effective for debriding the epithelial lining of pd pckt. . Sod hypochlorite solution ( Antiformin) . alk. – resulting in a narrow band of of necrotic tissue which strips off the inner lining 3. Caustic agents : Stewart H (1899) .Antiformin : coagulates the soft tissues – removal of inflammed tissue Disadv : extent of destruction not controlled. Ultrasonic Curettage : (Nadler 1962 ) .2.Induce chemical curettage of lateral wall of pocket . dismember collagen bundles alter morphologic features of fibroblast nuclei – Goldman 1961 .Vibrations disrupt tissue continuity. lift off epithelium. 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 . 3.Prerequisites : 1. Functionally adequate zone of attached that must exist apical to the base of the gingival pocket Indications : Glickman 1956 : 1. Eliminate gingival / suprabony pockets Eliminate gingival enlargements Eliminate suprabony periodontal abcesses . 2. Reduced inflammation 2. endodontic & /or prosthetic purposes . Eliminate gingival pockets 2. Transform rolled/ blunted margins to ideal physiologic form Correct soft tissue craters Gain additional crown length for restorative . 4. Create aesthetic tooth form & gingival symmetry in cases of delayed passive eruption and gingival enlargement 3. 5.Clarke : 1. . . 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 : . gigival enlargement Incision : similar to gingivectomy Taper the gingiva. thin attached gingiva. create scalloped outline. craters . shelf like interdental papillae caused by ANUG.Gingivoplasty: No pocket elimination Recontour gingiva Gingival clefts. create vertical interdental grooves shape interdental papillae to provide sluiceways . necrotic debris and monolayer of PMNs 24hrs – ct cells .Healing after gingivectomy : Surface clot (mins ) within 12hrs . 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 . crest fibres occur more slowly (Tonna et al 1967 ) . Hydroxide (Loe H ) disadv : excessive tissue injury .gingival remodeling no effective .epith & reformation of JE and reestablishment of the alv.Chemical method : 5 % paraformaldehyde (Orban 1942) . Stanton et al 1969 – complete epithelialization takes about 1 month Complete repair – 7 weeks Other methods : .Electrosurgery . Pot. pericoronal flaps Technique : needle electrode + small ovoid loop / diamond shaped electrodes for festooning . gingivoplasty. relocation of frenum & muscle attachments . loss of pd support touches root – areas of cementum burn Uses : gingival enlargements . incision of pd.Electrosurgery : Adv : permits contouring of ts and control hemorrhage Disadv : noncompatible/ poorly shielded cardiac pacemakers unpleasant odour heat generated – tissue damage .abscesses.shaving gentle motions : fully rectified current . loss of bone ht. tooth mobility . Malone et al 1969 : no difference btw scalpel . electrosurgery Pope et al 1968 : difference – delayed healing . more bone injury Glickman & Imber : gingival recession . greater reduction in gingival height . bone necrosis & sequestration .Healing after electrosurgery : Fisher et al 1983. furcation exposure . if adequate gingiva is present coronal to the frenum .Frenectomy / frenotomy : Frenum : band of fibrous tissue covered with mucosa extending from the lip . no need to remove it surgically . tongue & cheek to the alveolar periosteum -Types of frenal attachments -Effects ? .Indications . increase rate of periodontal recession and recurrence after treatment .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. . 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 . 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 .Frenectomy / frenotomy . not scar tissue. The frenectomy combined with a laterally positioned pedicle graft. A pedicle graft laterally positioned across the midline to obtain primary closure gingiva across the midline . . Objective : obtain orthodontic stability without compromising the aesthetics Miller PD. Gingivoplasty labially or palatally to remove any excessive tissue. Functional and aesthetic considerations.Miller 1985 Frenectomy – interdental papilla undisturbed. 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. Kazanjian s Lip switch technique (Transpositional Flap Vestibuloplasty) Obwegeser „s technique Clark s technique . 3. 2. 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 . Wentz.Crown lengthening procedures : Short clinical crowns : unaesthetic . Orban 1961 . 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 . 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 .75mm – 4.Variations exist : Vacek et al 1994 : BW – patient specific Range of 0. equigingival or subgingival Subgingival : create adequate resistance and retentive form caries / tooth deficiencies mask the tooth.restn margin . Restorations : supragingival.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. Body s response : . post treatment gingival margins Radiographs Probing under LA . Evaluate the gingival morphology. amt of residual tooth structure.Evaluation : Evaluate clinically – caries.BW : marginal gingiva to bone – sulcus depth . Cosmetic improvement . Enabling restorative treatment without impinging on biologic width 3.Objectives : l. Removal of subgingival caries 2.Facilitation of improved oral hygiene 5. Correction of occlusal plane 4. Diagnostic considerations include: l. Whether the clinical crown/root ratio after restorative treatment may be unfavorable 3. Root length and root morphology 4. Subgingival caries and the degree of extension of the clinical crown fracture apically 2. Residual amount of supporting bone after crown lengthening (especially osseous resection) . which may complicate maintenance 7. Increasing tooth mobility due to diminished supporting tissue and its influence on occlusion 8. The possibility of furcation exposure as well as unfavorable exposure of root surface (including grooves).5. Whether proper plaque control can be maintained after the placement . The degree of periodontal support lost from the adjacent tooth 6. . different gingival margins . Simple Crown Lengthening .short crowns.Procedures : 1.esthetic crown lengthening .gingivectomy/ recountouring . Compound crown lengthening : functional lengthening .2. Walsh 2003. CO2 . gingivoplasty. frenectomy. Schwarz et al 2001. Haytac et al 2006. Er: YAG – soft tissue procedures FDA clearance – 1976 Pick RM et al 1985 – CO2 laser – gingivectomy CO2 laser – gingivectomy . diode laser … Aoki et al 1994 . . adjunct to non surgical & surgical procedures Nd: YAG laser .Lasers The New Scalpel???? Lasers – Nd:YAG. . hemostasis Cobb 2006 : No evidence to show that lasers are superior to SRP or advantageous over scalpel in soft tissue procedures.Nd: YAG laser : soft tissue curettage Radvar et al 1996 – no statistically significant bacterial reductn Diode laser : Moritz et al 1997 . Hemostasis and post op discomfort less. healing delayed … (AAP Review) . „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. Depigmentation Melanin.Gingivoabrasion . Physiologic / pathologic Rationale : aesthetics!!! Criteria for case selection : . electrosurgery.adequate thickness of the tissues Techniques – chemical . amalgam etc.Combination . bilirubin.healthy periodontium .disparity btw skin tone & gingival colour . cryosurgery. lasers .Split thickness epithelial excision . surgical . iron. metals – bismuth.. 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 . 10th edition 2. Ratnadeep Patil – Aesthetic Dentistry 7. Sato – Clinical Atlas 6. 1996 8. 1995. Lindhe – 4th ed 3. Perio 2000 – 2004. 2001.References : 1. 9. Peterson – Oral and Maxillofacial Surgery 5. Caranza 8 th. JP2006.JP2002. Net References . Clarke – Clinical dentistry : Periodontal and Oral surgery 3rd ed 4. 9th ed. Courage is not always a roar. Have a good weekend ! . Sometimes it’s a quite voice at the end of the day saying “ I will try again tomorrow.” Thank you.