Periodontal & Gingival Curettage and Flaps
1/ Introduction :
The word curettage is used in periodontics to designate the removal of the gingival wall of a periodontal pocket thereby eliminating the affected soft tissue.
-Some authors differentiate curettage (gingival) in the case of a gingival pocket (gingivitis) from subgingival curettage (radicular, periodontal) in the case of a periodontal pocket (periodontitis).
-In any case, this therapeutic process aims to achieve healing by bringing together dental and gingival tissues made biologically compatible.
2/ Definition: According to
- Glickman in 1973: Periodontal curettage involves removing the degenerated tissue that lines the gingival wall of the periodontal pockets.
• Lindhe in 1986: Periodontal curettage is defined as the removal using a curette of the internal face of the soft tissue wall of the pocket.
• The American Academy of Periodontology (AAP) in 1989: Defines gingival curettage as follows: “Gingival curettage consists of scraping the soft tissues of the gingival wall of a periodontal pocket.”
3/ Reminder on the periodontal pocket:
Periodontal & Gingival Curettage and Flaps
4/ Objectives of curettage;
- Remove pathological epithelial tissue bordering the pocket and epithelial tissue obliterating the base of the pocket.
- Remove contaminated inflammatory connective tissue (granulation tissue)
- Reduce pocket depth by facilitating contraction of the gingival wall.
- Create an environment favorable to the reattachment of gingival fibers and epithelium.
5/ Contraindication of curettage:
- Local contraindications:
- Unmotivated patients: Patients who are uncooperative during etiological therapy should not undergo surgical treatment.
- General contraindications:
Absolutes
- Heart diseases (rheumatic endocarditis, congenital lesions, valvular and vascular prostheses).
- Hematological disorders (acute leukemia, agranulocytosis, lymphogranulomatosis, uncompensated anemia, hemophilia).
- Neurological disorders (Severe forms of multiple sclerosis, PARKINSON’s disease).
- Immunocompromised patients
- Cervicofacial radiotherapy.
- Pregnant woman (first and last trimester).
Relative Contraindications
- High blood pressure
- Angina pectoris
- Patients with a history of myocardial infarction
- Patients on anticoagulants
- Unbalanced diabetes
- Patients on corticosteroids
3/ Classification :
A difference has been established between gingival curettage and open curettage (flaps).
1. Gingival curettage : ( blind curettage)
Soft tissue curettage, closed curettage.
Technique by which the pocket epithelium and the infiltrated connective tissue are removed without making a flap, that is, without direct vision of the root surfaces.
2. Open curettage:
Technique by which the removal of the pocket epithelium and connective tissue is done under direct vision, obtained after an incision and the detachment of a flap.
3. ENAP (New exciting attachment) :
This technique consists precisely of a periodontal curettage carried out with a scalpel blade consisting of a minimum elevation of periodontal tissue to gain access to the root surface.
Indications:
- Elimination of false pockets in the case of edematous or slightly hypertrophic gingivitis.
- Elimination of suprabony pockets (≤5mm) located in accessible areas with a soft, edematous wall.
- Site preparation for surgery in the case of pockets larger than 5mm.
- Patients in whom surgery is contraindicated
- Periodontal abscess
Contraindications
- Unmotivated patient
- Gingival wall of fibrous consistency
- Infrabony pockets;
- Pockets greater than 5mm;
- Furcation damage.
Periodontal & Gingival Curettage and Flaps
Indications:
- Suprabony periodontal pocket not exceeding the mucogingival line
- soft-walled pockets.
- In the upper incisor-canine regions, this procedure presents an interesting compromise compared to classic flaps because it combats gingival recession.
- In the elimination of pockets of depth of 4 to 5 mm, if no surgical bone or muco-gingival correction is necessary
Technique:
* Internal bevel incision from the apex of the alveolar rim, into the gingival connective tissue below the sulcus and junction epithelium, to the bony crest
* The separated tissue is removed using a curette.
* Root planing.
* Compression for hemostasis and sutures.
Periodontal & Gingival Curettage and Flaps
Root planing is extremely difficult during closed curettage (without visual control), because of various root irregularities such as depressions and grooves.
On the other hand, open curettage greatly simplifies curettage and root planing.
Definition of a flap:
The periodontal flap is a portion of gum that has been surgically detached from its dental and bony support.
The flap intervention:
It is an intervention which consists of lifting a tissue flap “freed” by an incision in order to access the underlying root and bone structures.
Objectives of the flaps:
- Accessibility of instruments to root surfaces
- Elimination of inflammation
- Assessment of the degree of bone lysis
- Creating an oral environment that allows for effective plaque control
- Elimination of periodontal pockets
- Highlighting bone defects in order to adopt the best treatment (filling, guided bone regeneration, etc.)
- Regeneration of lesions induced by periodontal disease
- Resolution of mucogingival problems
- Improved aesthetics
- Development of a periodontal environment compatible with restorative dentistry procedures and prosthetic treatments
- Preservation of attached gingiva by use of an internal bevel incision.
Advantages of flaps:
- the use of an internal bevel incision allows the removal of
pocket epithelium and preservation of existing attached gingiva;
- the root surfaces thus exposed will allow effective root scaling and planing to be carried out right down to the bottom of the pockets;
- The marginal alveolar bone being exposed this will allow the highlighting of defects in bone morphology and guarantees the performance of correct treatment;
- The inter-radicular spaces are exposed 🡺 the extent of the damage can be assessed and the “tooth-bone” relationship can be examined;
- At the end of the operation, the flap can be replaced at its original level or moved apically, coronally or laterally relative to the original position;
- Interdental or infraosseous bone loss can be covered by flaps;
- The loss of substances is limited.
There are several flaps
- The simple flap (non-repositioned flap):
This is a flap replaced in its pre-surgical position at the end of the operation.
-It aims to eliminate periodontal pockets
- Repositioned flaps:
Its objectives are expanded beyond the elimination of pockets, it also allows the correction of muco-gingival lesions and the restoration of tissues destroyed by the disease.
Some flaps are called full thickness and others are called partial thickness.
Full thickness flaps:
The discharge incisions are clean and seek bone contact.
This type of flap allows access to the root surfaces and alveolar bone
The bone is exposed.
Partial thickness flap:
The discharging incisions are very light and do not seek bone contact.
In this way, the gingival epithelium and its underlying connective tissue are separated from the periosteum; these flaps are more difficult to produce and require greater surgical skill.
The periosteum covers the bone
Periodontal & Gingival Curettage and Flaps
Surgical technique:
- Asepsis then local anesthesia;
- Internal incision to separate the healthy connective tissue on one side and the inflammatory tissue and epithelium lining the pockets on the other ;
- The gum is receding.
- Removal of remaining granulation tissue and epithelium;
- The root surfaces are carefully debrided.
- The flap is replaced in its original position.
- Interproximal stitches.
- Applying the dressing
- Post-operative advice
Periodontal & Gingival Curettage and Flaps
Conclusion :
- There are a growing number of periodontal therapies, surgical or non-surgical, all aimed at the preservation and restoration of the periodontium. The choice of a technique is based on compliance with the indications and the goal to be achieved by the intervention, where the practitioner will always ensure tissue economy and will make compromises between function and aesthetics when necessary.
- We will note that debridement, scaling and root planing remains an important step and governs the success of any technique.
- In all cases, maintenance of the treated sites is essential to validate our treatments in the long term.
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.