Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Gingival Surgical Procedures GINGIVAL SURGICAL ! limited to the gingival and not TECHNIQUES involving underlying osseous structures ! Gingival Curettage ! Gingivectomy ! Gingivoplasty ! Gingival Flap Gingival Curettage Gingival Curettage ! Curettage - removal of the gingival wall of a periodontal pocket to separate diseased soft tissue ! Theory ! Inadvertent curettage –Unintentional ! Reduces inflamed granulation tissue in currettage performed the soft tissue wall when scaling and ! removes epithelium lining allowing root planing healing with connective tissue attachment ! Reduced the bacteria AAP Position Paper on Gingival AAP Position Paper on Gingival Curettage Curettage ! Reality ! Academy Statement –J. Perio 2002 ! No new attachment occurs with gingival ! “Gingival curettage has no theraputic curettage healing is by long junctional benefit in treatment of chronic epithelium periodontitis and concludes that the ! Result do not differ from results dental community as a whole regards obtained by S/RP alone gingival curettage as a procedure with ! Code for Gingival Curettage dropped NO clinical value.” from AAP codes 1 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Gingival Curettage by any other Gingivectomy name ! Excisional New Attachment Procedures ! Indications (ENAP) ! Elimination of suprabony pockets in firm ! Ultrasonic curettage fibrous pockets ! Caustic drugs ! Elimination of gingival enlargements ! Elimination of suprabony abscesses Also has no clinical value Definition: Treatment Planning Considerations Current Dental Terminology (CDT-3) - Revised & Limitations - Begin with the End in Mind D4210 – Gingivectomy or gingivoplasty: …. for suprabony pockets which need access for ! How much keratinized tissue restorative dentistry, when is present? moderate gingival enlargements or aberrations are present, and when ! Can keratinized tissue be there is asymmetrical, or unesthetic sacrificed? gingival topography. Mucogingival Attached Junction KG–probe depth= Gingivectomy Technique Gingiva Keratinized Gingiva PD Measure pocket depth Mark with bleeding points Initial incision Apical to bleeding points 45 degree bevel to the root 2 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Healing after Gingivectomy ! Initial response-formation of protective clot, underlying tissue has acute PMN infiltrate and some necrosis ! Clot replaced by granulation tissue ! 24 hours increase CT and angioblast below surface layer ! 12-24 hours epithelial cells at margin migrate into the granulation tissue, beneath the necrotic tissue Esthetically/Functionally Short Healing after Gingivectomy Crowns ! After 5-14 days surface epithelization is complete, but keratinization is incomplete ! Vasodilation and vascularity begin to decrease about the 4th day and appear ! Gummy Smile normal by about 16 days. Epithelium ! Delayed grows about 0.5 mm per day. passive ! Complete repair of the connective tissue eruption takes about 7 weeks Dr. Russ Dylla Smiling Centrals = 25% wider than laterals and 10% wider than canines 8 mm Centrals + Canines = 20% longer than laterals Ratio= 1.2/1.0 3 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Surgical Stent 11mm Can the biologic width affect the position of the gingival margin? ! Important in esthetic areas ! Help prevent coronal rebound of the gingival margin following surgery Biologic Rationale Gargiulo et al.: J Periodont 32: 261-267, 1961 ! Supra-alveolar Sulcus = 0.69 mm Tissues or Depth Dentogingival Epi. Junction – 2.73 mm Attach. = 0.97 mm ! Biologic Width or CT = 1.07 mm attachment apparatus Attach – 2.04 mm 2.73 mm 4 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota 11 mm Attachment apparatus = ~2.04mm Vertical Mattress sutures Dr. Russ Dylla Gingivectomy by Electrosurgery Gingivectomy by Chemosurgery ! Advantage-hemorrhage control ! Difficult to control depth of action ! Disadvantage-contraindicated in patients ! Healing is slower with poorly shielded cardiac pacemakers ! NOT RECOMMENDED ! Can cause bone necrosis if tip touches bone and areas of cementum can be burned if tip touches those area ! Must be limited to superficial procedures 5 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Gingivectomy ! LIMITING FACTORS : Treatment of Gingival ! Amount of keratinized gingival ! Maintenance of esthetics Enlargement ! Require access to osseous defects for definitive defect correction ! Freq less post operative pain with procedure that will allow primary closure ! Heavy pigmentation may contraindicate treatment Techniques for reduction of gingival Chronic Inflammmatory Enlargement enlargement Edematous tissue -treated with S/RP "#Gingivectomy IF extremely fibrous and interferes $#Flap operation-APF with access, surgical removal may be %#Combined Techniques indicated Gingivectomy Can recon tour at margin if adequate KG Flap operation Can be used with soft friable tissue Need firmer tissue Conserves KG 6 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Combined Techniques: Gingivectomy and Gingiveplasty Downloaded from: Carranza’s Clinical Periodontology (on 10 August 2006 04:54 PM) © 2005 Elsevier Downloaded from: Carranza’s Clinical Periodontology (on 10 August 2006 04:54 PM) © 2005 Elsevier Treatment Planning Considerations & Limitations - Begin with the End in Mind Functional or esthetic compromise of involved or adjacent teeth ! Opening interdental spaces ! Creating excessively “long” teeth 7 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Gingival Diseases-Dental Plaque 1. Gingival Disease Induced ! Dental plaque-induced gingival diseases ! Gingival Diseases modified by medications ! Drug-influenced gingival diseases ! Drug-influenced gingival enlargements ! Drug-influenced gingivitis ! Oral contraceptive associated ! Other Esthetically/Functionally Short Crowns ! Inflammatory drug induced hyperplasia 8 of 9 Dr. Deby Johnson Periodontology III Spring Semester, 2009 School of Dentistry University of Minnesota Drugs causing overgrowth &Nifedipine &Cyclosporine &Phenytoin (Dilantin) credits ! Dr. James Le ! Dr. Allen Todd ! Coury Staadecker 9 of 9.