Surgical therapies for gingival diseases
Gingival curettage
Gingivectomy-gingivoplasty
Introduction: Scaling and curettage represent the most commonly used basic techniques for the elimination of periodontal pockets and the treatment of gingivopathies. We use the term periodontal curettage when we remove the pathological elements of the pocket: tartar, infiltrated tissue, granulation tissue and epithelial-connective attachment, to achieve healing of the pocket, without making an access incision .
The blind curettage technique should not be confused with subgingival scaling, which aims to remove a single pathological element: tartar. Like all periodontal surgery procedures, curettage should be performed after reducing the inflammation. Careful supragingival and subgingival scaling will precede periodontal curettage.
Reminder on the periodontal pocket:
-Definition : a periodontal pocket is a pathological deepening of the gingival groove.
-Composition of the periodontal pocket:
-The hard wall : represented by the root surfaces
-The soft wall : formed by an inflamed gingival wall
-Content : The pockets contain microorganisms and their degradation products, gingival fluid, food debris, desquamated epithelial cells, and leukocytes.
-The bottom of the pocket : represented by the superficial cells of the junctional epithelium.
Gingival curettage
1-Definition : curettage is defined as the removal, using a curette, of the internal face of the soft tissue wall of the pocket. We distinguish
- blind curettage
- Open curettage
2-Goals:
-removal of the pocket epithelium and inflamed connective tissue results in the formation of a new connective and/or epithelial attachment at the dental surface.
-The tissue contraction that follows curettage contributes to the reduction of pocket depth.
-Remove the inflamed gum wall
-Remove granulation tissue
-Clean and polish root surfaces
-Detach the epithelial attachment.
3-Indications:
-inflamed tissue with potential for contraction
-shallow pocket (3 to 4mm)
-Aesthetic compromise in the anterior region
-Preparation for deeper surgery in complex cases.
-most varieties of gingivitis, except gingival hypertrophy.
4-Contraindications:
-Fibrous gingival tissues
-Deep pockets
-Imperfect periodontal care and lack of regularity of check-ups
5- Advantages:
-Simple technique
-Limited instrumentation
-Very simple post-operative course
-Little aesthetic damage
-Little dentin hypersensitivity
6-Disadvantages:
-Technique requiring dexterity
-Technique still incomplete
-Difficulty reaching concavities, furcations, bone defects.
-Possibility of recurrence of pockets.
7-Instrumentation: the tray must include
A mirror, tweezers, anesthesia equipment, scrapers, curettes,
Surgical therapies for gingival diseases
8-Operating techniques:
-Isolate the surgical field and clean it with an antiseptic (lower part of the face and mouth).
-Topical, local or regional injectable anesthesia .
-Remove supragingival tartar using supragingival scrapers
-Remove subgingival tartar by inserting a subgingival scraper into the bottom of the pocket, just below the lower edge of the tartar, to detach it.
– Polishing of root surfaces : Hoe-shaped scrapers are used to remove deep deposits, necrotic cementum and polish the root surfaces. A final polish is obtained with curettes which give rise to significantly smoother surfaces.
-curet the gingival wall : remove the granulation tissue (internal pathological lining) and the epithelial attachment. For this purpose, curettes with cutting edges on both sides of the blade are used in order to be able to level the root at the same time. The removal of the internal lining of the pocket wall and the epithelial attachment is done in two stages. The curette is inserted so that it attacks the internal lining of the pocket wall, and it is moved along the soft tissues until it reaches the crest of the gingiva. The pocket wall is supported by gentle digital pressure applied to the external face. The curette is then placed under the cut edge of the epithelial attachment, in order to remove it. The epithelial attachment is removed by a hollowing movement of the curette towards the tooth surface.
– polishing the tooth surfaces: After polishing the root surfaces, the field is cleaned and light pressure is applied to adapt the gum around the tooth.
– revision of the wound, and application of the dressing : abundant washing of the wound with physiological serum ensures effective cleaning. Protect the wound with surgical cement left in place for a week.
9-Post-operative advice:
-Oral hygiene : it is essential for good healing. It includes brushing teeth but also mouthwashes. (Givalex R , Hextril R , Eludril R , Alodent R ) after each meal, and which will be started the day after an intraoral intervention, associated with the use of dental floss.
– Diet : refeeding can begin, if possible, the same evening as an oral procedure. Solid foods, hot or acidic liquids (fruit juices) or spicy foods should be avoided; however, iced drinks are recommended.
– prescription of analgesics : the fight against post-operative pain (which is almost constantly found) is a priority to which we must pay even more attention since a well-analgesed patient will be reassured and will follow the post-operative prescriptions with greater compliance.
– the prescription of aspirin is not recommended due to its antiplatelet effect, which can be the source of postoperative hemorrhage and hematomas.
– avoid certain combinations of antagonist analgesics e.g.: Efferalgan codeine + Temgesic)
– The use of high-dose non-steroidal anti-inflammatory drugs for analgesic purposes such as niflumic acid (Nifluril) or ibuprofen (Neurofen) should be avoided or prohibited due to the risk of extending a possible septic process, particularly in cellulitis of dental origin.
-The analgesic of choice seems to be paracetamol. The usual dosage is 20 to 30 mg/kg/day, which corresponds to 1 to 2 tablets one to three times a day (without exceeding 9 tablets of 500 mg per day). There is nevertheless a single contraindication: severe hepatocellular insufficiency. This molecule is not teratogenic and can therefore be used in children and pregnant women.
-As a second option and for more intense pain that does not respond well to paracetamol alone, a combination of paracetamol+codeine, in the form of Codoliprane tablets, is prescribed; the dosage is 2 tablets three times a day.
-Application of ice compresses.
Surgical therapies for gingival diseases
10-Healing :
-just after treatment, the faces are smooth: there are some cracked and fragmented areas , in some parts the cementum is completely removed.
-three or four weeks after denudation, a hypermineralized superficial zone appears, produced by the exchange of minerals and organic components at the interface of saliva and the root.
-just after scaling and curettage, a blood clot fills the gingival sulcus. We then observe a rapid proliferation of granulation tissue accompanied by a decrease in the number of blood vessels, as the tissue reaches maturity. Restitution and epithelialization occur within two to seven days. Immature collagen fibers appear within 21 days following treatment.
Cut gingival fibers, and tears in the sulcular epithelium and epithelial attachment are repaired during healing.
-after a week the gum is lowered due to the shrinkage of the marginal gingiva and the change in its position. The gum is a little redder than normal due to the increase in vascularization that accompanies healing.
-after two weeks the gum has returned to its normal color, consistency, surface texture and usual contour.
-Conclusion :
Periodontal curettage associated with other stages of initial preparation (hygiene motivation and elimination of iatrogenic factors) becomes an essential act of the pre-surgical phase. Similarly, it may be considered during certain maintenance sessions.
-Bibliography:
– Irving Glickman clinical periodontology, prevention, diagnosis and treatment of periodontal diseases in the context of general dentistry cdp edition 57 rue dulou 75017 Paris
– Jean Lindhé manual of clinical periodontology cdp edition
– JFTecucianu Periodontal surgery EMC 23602 A10 66-1978
– JJBarrelle, Simon Hirsch introduction to periodontology publication AGECD legal deposit 1973
– L Chikhani, F Guilbert , postoperative care in stomatology and maxillofacial surgery. EMC stomatology-odontology 22-091-p-10, 1995,4p.
Surgical therapies for gingival diseases
Good oral hygiene Regular scaling at the dentist Dental implant placement Dental x-rays Teeth whitening A visit to the dentist The dentist uses local anesthesia to minimize pain