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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.
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
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
lining.
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
A, B. Preoperative.
C, D. Incision
E, F. Flap reection.
G, H. Suture.
I, J. 1 week of healing.
K, L. 8 weeks follow-up.
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.
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.
A.
B.
* 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.)