CHAPTER 52 & 56

PHASE II (SURGICAL PHASE) / GINGIVAL SURGICAL TECHNIQUES

main objectives of phase II / surgical phase

improvement of esthetics

improvement of the prognosis of teeth and their replacements

second objective of the phase II

the correction of anatomic morphologic defects that may favor plaque accumulation and pocket recurrence or impair esthetics

purpose of surgical pocket therapy

to promote periodontal regeneration

to create a stable, easily maintainable state

to eliminate the pathologic changes in the pocket walls

2 classification of pocket therapy

active state

inactivity / quiescence

active pocket

in this, the underlying bone is being lost

can be diagnosed clinically by bleeding, either spontaneously or on probing

inactive pockets

can heal with long junctional epithelium, but may be unstable and recurrent due to weak tooth epithelial union

maintaining attachment with frequent scaling and root-planing procedures is possible.

plastic surgery techniques

used to create or widen the attached gingiva by placing grafts of various types

esthetic surgery techniques

used to cover denuded roots and to recreate lost papillae.

preprosthetic techniques

used to adapt the periodontal and neighboring tissues to receive prosthetic replacements

these include crown lengthening, ridge augmentation, and vestibular deepening

critical zones in pocket surgery

zone 1: soft tissue pocket wall

Zone 2: tooth surface

Zone 3: underlying bone

Zone 4: attached gingiva

zone 1: soft tissue pocket wall

the clinician should determine the morphologic features, thickness, and topography of the soft tissue pocket wall and persistence of inflammatory changes in the wall.

zone 2: tooth surface

the clinician should identify deposits and alterations on this surface, determine root surface accessibility

evaluate phase I therapy results to determine the need for further therapy and method.

zone 3: underlying bone

the clinician must determine the alveolar bone's shape and height through probing, clinical examinations, and radiographics, considering bone deformities, craters, and other factors in treatment selection.

zone 4: attached gingiva

the clinician should consider the presence or absence of an adequate band of attached gingiva when selecting a pocket treatment method, considering factors like high frenum attachment, gingival recession, or deep pockets.

indications for periodontal surgery

persistent inflammation

grade II or III furcation involvement

irregular bony contours, deep craters

intrabony pockets on distal last molars

persistent inflammation in moderate to deep pockets

pockets on teeth where root irritant removal is not possible

3 methods of pocket therapy

new attachment techniques

removal of the pocket wall

removal of the tooth side of the pocket

new attachment techniques

offer the ideal result

eliminate pocket depth by reuniting gingiva to tooth at coronal position

often involving bone filling and regeneration of periodontal ligament and cementum.

removal of pocket wall

the most common method of pocket therapy

2 factors to consider in gingival pocket therapy

character of the pocket wall

accessibility of the pocket

curettage

the scraping of the gingival wall of a periodontal pocket to remove diseased soft tissue

the removal of the chronically inflamed granulation tissue that forms in the lateral wall of the periodontal pocket

scaling

refers to the removal of deposits from the root surface

planing

smoothing the root to remove infected and necrotic tooth substance

2 classification of curettage

gingival curettage

subgingival curettage

gingival curettage

consists of the removal of the inflamed soft tissue lateral to the pocket wall and the junctional epithelium

subgingival curettage

refers to the procedure that is performed apical to the junctional epithelium and severing the connective tissue attachment down to the osseous crest.

inadvertent curettage

refers to when curettage is accomplished unintentionally during scaling and root planing

indications for curettage

attempts in moderately deep intrabony pockets in accessible areas

reduce inflammation in patients with systemic issues & compromises pocket elimination and prognosis

performed on recall visits for recurrent inflammation and pocket depth, especially in cases of pocket reduction surgery

excisional new attachment procedure (ENAP)

it is a definitive subgingival curettage procedure performed with a knife.

drugs that induce a chemical curettage of the lateral wall of the pocket

phenol

sodium sulfide

alkaline sodium hypochlorite solution (antiformin)

gingivectomy

involves the excision of the gingiva

the objective is to eliminate pocket

despite advancements in flap methods, it remains effective

allowing for the removal of calculus and root smoothing, promoting healing and restoring a physiologic gingival contour

prerequisites of gingivectomy

there should be no infrabony defects or pockets

always consider the amount of unattached gingiva remaining

there should be adequate zone of attached gingiva so that excision of part of it will still leave a functionally adequate zone

the underlying alveolar bone must be in normal or nearly normal form, if there is bone loss it should be of horizontal in nature

indications of gingivectomy technique

correct gingival craters

eliminate gingival enlargements

eliminate suprabony periodontal abscesses

transform rolled or blunted margins to physiologic form

remove fibrous or edematous gingiva enlargements

eliminate suprabony pockets, regardless of depth

create more esthetic form in cases where anatomic crown exposure hasn't fully occurred

expose additional clinical crown for restorative procedures

create bilateral symmetry

contraindications of gingivectomy technique

esthetic considerations, particularly in the anterior maxilla

situations in which the bottom of the pocket is apical to the mucogingival junction

the need for bone surgery or examination of the bone shape and morphology

contraindications of gingivectomy & gingivoplasty

uncooperative patients

medically-compromised patients

when infrabony pockets are present

inadequate oral hygiene maintenance by the patients

if pockets extends till/below the mucogingival junction

esthetically challenging areas, especially in the maxillary anterior region

in the presence of thick alveolar edges, interdental craters or bizarre crestal bone form

dentinal hypersensitivity before the surgical procedure (requires considerable preparation of the patient mentally and is not exactly a contraindication)

gingivectomy technique may be performed by means of:

lasers

scalpels

chemicals

electrodes

steps of surgical gingivectomy

use periodontal probe to explore pockets and mark their course

use periodontal knives for incisions on facial, lingual, distal to teeth, and interdental surfaces

examine excised pocket wall, clean area, and root surface for calculus remnants, root caries, resorption, and granulation tissue

carefully curette granulation tissue and remove remaining calculus and necrotic cementum

cover area with a surgical pack

gingivoplasty

a surgical procedure

first described by Goldman in 1950

eliminating periodontal pockets

reshaping the gums for a more natural appearance

involves reshaping the gingiva to create physiologic contours

resembling artificial denture festooning, aims to restore gingiva's physiologic form without reducing sulcular depth

steps of gingivoplasty

tapering the gingival margins

scalloped marginal outline

thinning of the attached gingiva and creating vertical interdental grooves

shaping the interdental papillae to provide sluice ways for the passage of food

gingivoplasty may be accomplished by means of:

scalpel

electrodes

periodontal knife

rotary coarse diamond stones

gingival deformities caused by gingival & periodontal dx

gingival enlargements

gingival clefts and craters

craterlike interdental papillae caused by ANUG

factors that current periodontal surgery must consider

conservation of keratinized gingiva

minimal gingival tissue loss to maintain esthetics

adequate access to the osseous defects for definitive defect correction, and

minimal postsurgical discomfort and bleeding by attempting surgical procedures that will allow primary closure.

types of gingivectomy

laser gingivectomy

surgical gingivectomy

gingivectomy by electrosurgery

gingivectomy by chemosurgery

electrosurgery (surgical diathermy)

uses high frequency current of 1.5 to 7.5 million cycles per second

3 classes of electrodes used in electrosurgery

loop electrodes — for planing tissues

single wire electrodes — for incising and excising

heavy bulkier electrodes — for coagulation procedures

4 types of electrosurgical techniques

electrosection

electrofulguration

electrodesiccation

electrocoagulation

electrosection

3 procedures are performed:

• incising

• excising

• planing

electrocoagulation

used to prevent hemorrhage

electrofulguration

uses high voltage current

it has limited application in dentistry

electrodesiccation

uses dehydrating current and least used, as it is a dangerous technique

advantage of gingivectomy by electrosurgery

permits adequate contouring of the tissues and controls hemorrhage

disadvantages of gingivectomy by electrosurgery

causes unpleasant odor

if it touches the bone irreparable damage may result

cannot be used in patients with poorly shielded cardiac pacemaker

heat generated by this may cause tissue damage and areas of cemental necrosis

indications of gingivectomy by electrosurgery

gingivoplasty

removal of gingival elements

relocation of frenum and muscle attachments

incision of periodontal abscesses and pericoronal abscess

needle electrodes & diamond-shaped electrodes

shaving motion

used for festooning & reshaping procedures

needle electrode

used for abscess drainage

ball electrodes

used for hemostasis

loop electrode

used for relocation of frenum and muscle attachment

laser gingivectomy

carbon drovide — most commonly used lasers

they are used for excision of gingival over growth

their use in periodontal surgery is not supported by research

gingivectomy by chemosurgery

5 percent paraformaldehyde / potassium hydroxide to remove gingiva

disadvantages of gingivectomy by chemosurgery

healing is delayed

gingival remodeling is not possible

their depth of action cannot be controlled hence it may also inure normal tissues