Periodontal Surgery:Access Therapy

Since most forms of periodontal disease are plaque associated disorders ,

it is obvious that surgical access therapy can only be considered as adjunctive to cause -related

therapy. Therefore, the various surgical methods described below should be evaluated on the basis of their potential to facilitate removal of subgingival deposits and self-performed plaque control and thereby enhance the long-term

preservation of the periodontium .

The decision concerning what type of periodontal surgery should be performed and how many sites should be included is usually made after the effect of initial cause-related measures has been

evaluated .The time lapse between termination of the initial cause-related phase of therapy and this evaluation may vary from 1 to 6 months.

This routine has the following advantages:- • The removal of calculus and bacterial plaque will eliminate or

markedly reduce the inflammatory cell infiltrate in the gingiva (edema, hyperemia, flabby tissue consistency), thereby making assessment of the "true" gingival contours and pocket depths possible.

• The reduction of gingival inflammation makes the soft tissues more fibrous and thus firmer, which facilitates surgical handling of the soft tissues. The propensity for bleeding is reduced, making inspection of the surgical field easier.

•A better basis for a proper assessment of the prognosis has been established. The effectiveness of the patient's home care, which is of decisive importance for the long-term prognosis, can be properly evaluated.

Lack of effective self-performed care will often mean that the patient should be excluded from surgical treatment.

Indications _Gingival enlargement or overgrowth (caused by

medicaments or hormonally) - Idiopathic fibrosis _ Suprabony pockets in areas with limited

access _ Minor corrective procedures

Contraindications _Narrow or absent attached gingiva

–Infrabony pockets _ Thickening of marginal alveolar bone

Advantages _Technically simple; good visual access

_ Complete pocket elimination

Disadvantages -Very limited indication

_ Gross wound; postoperative pain _ Healing is by secondary intent (ca. 0.5 nun re-

epithelialization per day) - Danger of exposing bone

_ Sacrifice of attached gingiva _Exposes cervical area of tooth (sensitivity,

esthetics caries) _ Phonetic and esthetic problems in anterior

areas

Principles of the operative procedure _Continuous incision at 45° angle toward the

base of the pocket _ Sharp dissection of tissues in the interdental

areas _ Smoothing of the incision edge

-Scaling and root planing _ Contouring of the gingival surface (GP) _ Wound coverage (periodontal dressing;

tissue adhesive)

Gingivectomy proceduresThe surgical approach as an alternative to subgingival scaling for pocket therapy was already recognized in the latter part of the nineteenth century, when Robicsek (1884) pioneered the so-called gingivectomy procedure.

Gingivectomy was later defined by Grant et al. ( 1979) as being "the excision of the soft tissue wall of a

pathologic periodontal pocket ."The surgical procedure, which aimed at "pocket elimination", was usually combined with recontouring

of the diseased gingiva to restore physiologic form .

Pocket marking forceps

Gingivectomy knives

GV knife (Kirkland

-Papilla knife (Orban

Universal knife

Electrosurgery - Device and tips Electrosurgery finds its primary function in the gingivoplasty procedure, where it is useful for contouring soft tissue, for papillectomy, for smoothing out abrupt tissue edges, and for exposing the margins of restorations. Electrosurgery is not recommended for expansive gingivoplasty because of the possibility of injury to the tooth root, periosteum, bone or the tooth pulp.

TechniqueThe gingivectomy procedure as it is employed today was

described in 1951 by Goldman.• When the dentition in the area scheduled for surgery has been

properly anesthetized, the depths of the pathologic pockets are identified with a conventional periodontal probe (Fig. 3a).

At the level of the bottom of the pocket, the gingiva is pierced with the probe and a bleeding point is produced on the outer surface of the soft tissue (Fig. 3b).

The pockets are probed and bleeding points produced at several location points around each tooth in the area.

The series of bleeding points produced describes the depth of the pockets in the area scheduled for treatment and is used as a guideline for the incision.

Fig. 3. Gingivectomy. Pocket marking. (a) An ordinary periodontal probe is used to identify the bottom of the deepened pocket. (b) When the depth of the pocket has been assessed, an equivalent distance is delineated on the outer

aspect of the gingiva .The tip of the probe is then turned horizontally and used to produce a bleeding point at the level of the bottom of the probeable pocket.

Gingivoplasty electrosurgical loop

Pocket marking forceps

•The primary incision (Fig. 4), which may be made by a scalpel (blade No. 12B or 15; or a Kirkland knife No. 15/16, should be planned to give a thin and properly festooned margin of the remaining gingiva.Thus, in areas where the gingiva is bulky, the incision must be placed at a level more apical to the level of the bleeding points than in areas with a thin gingiva, where a less accentuated bevel is needed.

The beveled incision is directed towards the base of the pocket or to a level slightly apical to the apical extension of the junctional epithelium .

.

• In areas where the interdental pockets are deeper than the buccal or lingual pockets, additional amounts of buccal and/or lingual (palatal) gingiva must be removed in order to establish a "physiologic" contour of the gingival margin.

• This is often accomplished by initiating the incision at a more apical level

Fig. 4. Gingivectomy. (a) The primary incision. (b) The incision is terminated at a level apical to the "bottom" of the pocket and is angulated to give the cut surface a distinct bevel

•Once the primary incision is completed on the buccal and lingual aspects of the teeth, the interproximal soft tissue is separated from the interdental periodontium by a secondary incision using an Orban knife (No. 1 or 2) or a Waerhaug knife (No. 1 or 2; a saw-toothed modification of the Orban knife; Fig. 25-5).

Fig. 6. Gingivectomy. The detached gingiva is removed with a scalerFig. 5. Gingivectomy. The secondary incision

through the interdental area is performed with the use of a Waerhaug knife.

• The incised tissues are carefully removed by means of a curette or a scaler (Fig. 25-6). Remaining tissue tabs are removed with a curette or a pair of scissors.

Pieces of gauze packs often have to be placed in the interdental areas to control bleeding.

When the field of operation is properly prepared, the exposed root surfaces are carefully scaled and planed.

• Following meticulous debridement, the dentogingival regions are probed again to detect any remaining pockets (Fig. 7). The gingival contour is checked and, if necessary, corrected by means of knives or rotating diamond burs.

• To protect the incised area during the period of healing, the wound surface must be covered by a periodontal dressing (Fig. 8).

The dressing should be closely adapted to the buccal and lingual wound surfaces as well as to the interproximal spaces.

Care should be taken not to allow the dressing to become too bulky, since this is not only uncomfortable for the patient, but also facilitates dislodgement of the dressing.

Fig. 7. Probing for residual pockets. Gauze packs have been placed in the interdental spaces to control bleeding.

Fig. 8. The periodontal dressing has been applied and properly secured

• The dressing should remain in position for 10-14days. After removal of the dressing, the teeth must be cleaned and polished.

The root surfaces are carefully checked and remaining calculus removed with a curette. Excessive granulation tissue is eliminated with a curette.

The patient is instructed to properly clean the operated segments of the dentition, which now have a different morphology as compared to the preoperative situation.

Eugenol-free dressings Chlorhexidine powder

Anesthesia