Gingivectomy lecture.pptx in periodontics

Gingivectomy lecture.pptx in periodontics

1. Gingivectomy

2. The word gingivectomy means “ excision of the gingiva.” By removing the pocket wall, gingivectomy provides visibility and accessibility for complete calculus removal and the thorough smoothing of the roots. This creates a favorable environment for gingival healing and restoration of a physiologic gingival contour. Introduction

3. Introduction The gingivectomy procedure was first recognized by Robicsek (straight incision technique) as an alternative surgical approach to subgingival scaling for pocket therapy. Grant et al. later on defined gingivectomy as “the excision of the soft tissue wall of a pathologic periodontal pocket” to eliminate the pocket and restore a physiologic gingival contour.

4. The gingivectomy technique was widely performed in the past. Improved understanding of healing mechanisms and the development of more sophisticated flap methods have downgraded the gingivectomy to a lesser role in the current repertoire of available techniques. However, it remains an effective form of treatment when indicated. Introduction

5. Indications The gingivectomy technique may be performed for the following indications: 1. Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm. 2. Elimination of gingival enlargements. 3. Elimination of suprabony periodontal abscesses.

6. Contraindications Contraindications to gingivectomy include the following: 1. The need for bone surgery or examination of the bone shape and morphology. 2. Situations in which the bottom of the pocket is apical to the mucogingival junction. 3. Aesthetic considerations, particularly in the anterior maxilla.

7. Surgical Gingivectomy Step 1. The pockets on each surface are explored with a periodontal probe and marked with a pocket marker . Each pocket is marked in several areas to outline its course on each surface.

8. Marking the depth of a suprabony pocket. A, A pocket marker in position. B, The beveled incision extends apical to the perforation made by the pocket marker.

9. Step 2. Periodontal knives (e.g., Kirkland knives) are used for incisions on the facial and lingual surfaces and on those distal to the terminal tooth in the arch. Orban periodontal knives are used for interdental incisions. Bard–Parker blades (nos. 12 and 15) as well as scissors are used as auxiliary instruments. Surgical Gingivectomy

10. The incision is started apical to the points marking the course of the pockets and it is directed coronally to a point between the base of the pocket and the crest of the bone. It should be as close as possible to the bone without exposing it to remove the soft tissue coronal to the bone. Exposure of bone is undesirable. If this occurs, healing usually presents minimal complications if the area is adequately covered by the periodontal pack. Surgical Gingivectomy

11. Either interrupted or continuous incisions may be used. The incision should be beveled at approximately 45 degrees to the tooth surface, and it should recreate the normal festooned pattern of the gingiva. Failure to bevel the incision will leave a broad, fibrous plateau that will take a longer time to develop a physiologic contour. Surgical Gingivectomy

12. Step 3. Remove the excised pocket wall, clean the area, and closely examine the root surface. The most apical zone consists of a light, band like zone where the tissues were attached. Coronally, calculus remnants, root caries, or resorption may be found. Granulation tissue may be seen on the excised soft tissue. Surgical Gingivectomy

13. Step 4. Carefully curette the granulation tissue and remove any remaining calculus and necrotic cementum to leave a smooth and clean surface. Surgical Gingivectomy

14. Step 5. Cover the area with a surgical pack Surgical Gingivectomy

15. In most cases, after the surgical periodontal procedures are completed, the area is covered with a surgical pack . In general, dressings have no curative properties; they assist hea ling by protecting the tissue rather than providing “healing factors.” Periodontal Dressings (Periodontal Packs)

16. Periodontal Dressings (Periodontal Packs) The pack minimizes the likelihood of postoperative infection and hemorrhage. Facilitates healing by preventing surface trauma during mastication. Protects the patient from pain induced by contact of the wound with food or with the tongue during mastication.

17. Zinc Oxide–Eugenol Packs. Packs that are based on the reaction of zinc oxide and eugenol include the Wondr Pak, which was developed by Ward in 1923, and several other packs that use modified forms of Ward’s original formula. The addition of accelerators such as zinc acetate gives the dressing a better working time.

18. Zinc oxide–eugenol dressings are supplied as a liquid and a powder that are mixed before use. Eugenol in this type of pack may induce an allergic reaction that produces reddening of the area and burning pain in some patients. Zinc Oxide–Eugenol Packs.

19. Noneugenol Packs. The reaction between a metallic oxide and fatty acids is the basis for the Coe-Pak.

20. This is supplied in two tubes , the contents of which are mixed immediately before use until a uniform color is obtained. One tube contains zinc oxide, an oil (for plasticity), a gum (for cohesiveness), and Lorothidol (a fungicide). The other tube contains liquid coconut fatty acids that have been thickened with colophony resin (or rosin) and chlorothymol (a bacteriostatic agent). Noneugenol Packs.

21. This dressing does not contain asbestos or eugenol, thereby avoiding the problems associated with these substances. Other non-eugenol packs include cyanoacrylates and tissue conditioners (methacrylate gels).However, these are not in common use. Non-eugenol Packs.

22. Preparing the surgical pack (Coe-Pak).A, Equal lengths of the two pastes are placed on a paper pad. B, The pastes are mixed with a wooden tongue depressor for 2 or 3 minutes until, C, the paste loses its tackiness. D, The mixed paste is placed in a paper cup of water at room temperature. With lubricated fingers, it is then rolled into cylinders and placed on the surgical wound.

23. Retention of Packs Periodontal dressings are usually kept in place mechanically by interlocking in interdental spaces and joining the lingual and facial portions of the pack. In isolated teeth or when several teeth in an arch are missing, retention of the pack may be difficult. Numerous reinforcements and splints and stents for this purpose have been described.

24. A strip of pack is hooked around the last molar and pressed into place anteriorly.

25. B, The lingual pack is joined to the facial strip at the distal surface of the last molar and fitted into place anteriorly. C, Gentle pressure on the facial and lingual surfaces joins the pack interproximally.

26. Continuous pack covers the edentulous space.

27. Periodontal pack should not interfere with the occlusion .

28. Antibacterial Properties of Packs Improved healing and patient comfort with less odor and taste have been obtained by incorporating antibiotics into the pack. Bacitracin, oxytetracycline ( Terramycin ), neomycin, and nitrofurazone have been tried, but all of these may produce hypersensitivity reactions. The incorporation of tetracycline powder into the Coe-Pak is generally recommended, particularly when long and traumatic surgeries are performed.

29. Gingivoplasty Gingivoplasty is similar to gingivectomy, but its objective is different. Gingivectomy is performed to eliminate periodontal pockets, and it includes reshaping as part of the technique. Gingivoplasty is a reshaping of the gingiva to create physiologic gingival contours with the sole purpose of recontouring the gingiva in the absence of pockets.

30. Gingival and periodontal disease often produces deformities in the gingiva that are conducive to the accumulation of plaque and food debris, which prolong and aggravate the disease process. Such deformities include: (1) Gingival clefts and craters. (2)Craterlike interdental papillae caused by acute necrotizing ulcerative gingivitis. (3) Gingival enlargements. Gingivoplasty

31. Gingivoplasty Gingivoplasty may be accomplished with :1- a periodontal knife, 2- a scalpel , 3- rotary coarse diamond stones, 4- electrodes.

32. Gingivoplasty The technique resembles that of the festooning of an artificial denture, which consists of : tapering the gingival margin, creating a scalloped marginal outline, thinning the attached gingiva , creating vertical interdental grooves, and shaping the interdental papillae

33. Healing After Surgical Gingivectomy The initial response after gingivectomy is the formation of a protective surface blood clot . The clot is then replaced by granulation tissue . In 24 hours , there is an increase in new connective tissue cells, which are mainly angioblasts beneath the surface layer of inflammation and necrotic tissue.

34. By the third day , numerous young fibroblasts are located in the area. The highly vascular granulation tissue grows coronally and creates a new free gingival margin and sulcus. Capillaries derived from the blood vessels of the periodontal ligament migrate into the granulation tissue, and, within 2 weeks, they connect with the gingival vessels. Healing After Surgical Gingivectomy

35. After 12 to 24 hours, epithelial cells at the margins of the wound begin to migrate over the granulation tissue, thereby separating it from the contaminated surface layer of the clot. Epithelial activity at the margins reaches a peak after 24 to 36 hours. Healing After Surgical Gingivectomy

36. The new epithelial cells arise from the basal and deeper spinous layers of the epithelial wound edge and migrate over the wound over a fibrin layer that is later resorbed and replaced by a connective tissue bed. The epithelial cells advance by a tumbling action, with the cells becoming fixed to the substrate by hemidesmosomes and a new basement lamina. Healing After Surgical Gingivectomy

37. After 5 to 14 days , surface epithelialization is generally complete. During the fist 4 weeks after gingivectomy, keratinization is less than it was before surgery. Complete epithelial repair takes about 1 month . Vasodilation and vascularity begin to decrease after the fourth day of healing, and they appear to be almost normal by the sixteenth day. Complete repair of the connective tissue takes about 7 weeks . Healing After Surgical Gingivectomy

38. The flow of gingival fluid in humans is initially increased after gingivectomy, and it diminishes as healing progresses. Maximal flow is reached after 1 week , which coincides with the time of maximal inflammation. Healing After Surgical Gingivectomy

39. Although the tissue changes that occur during post gingivectomy healing are the same in all individuals, the time required for complete healing varies considerably, depending on the area of the incised surface and interference from local irritation and infection. In patients with physiologic gingival melanosis, the pigmentation is diminished in the healed gingiva. Healing After Surgical Gingivectomy

40. Conclusion The gingivectomy surgical technique has a long history of use in periodontal surgery. Current periodontal surgery must consider the following: (1) the conservation of keratinized gingiva ; (2) minimal gingival tissue loss to maintain aesthetics; ( 3) adequate access to the osseous defects for definitive defect correction; (4) minimal postsurgical discomfort and bleeding. The gingivectomy surgical technique has limited use in current surgical therapy because it does not satisfy these considerations for periodontal therapy. The clinician must carefully evaluate each patient to address the proper application of this surgical procedure.

41. 2. GINGIVECTOMY BY CHEMO SURGERY Agent Used. 25% phenol with 75% camphor. 5% paraformaldehyde in ZnO eugenol pack. ADVANTAGES OF CHEMOSURGERY No analgesia or anesthesia required for the procedure. Procedure is easy to perform & require less instruments.

42. Disadvantage Bone necrosis might result. Periodontal abscess might result. Delayed wound healing Subsequent plaque retention Bone resorption

43. 3. Gingivectomy by electro surgery Advantages: Less Bleeding Disadvantages Procedure produces heat which causes necrosis of adjacent tissue. If it transfer to the bone, resorption take place.

44. 4 . Gingivectomy by cryosurgery Temperature -50 to -60 c is apply to gingiva by means of a probe. Advantages The procedure does not cause pain & bleeding. 5 . Gingivectomy by LASER: TYPE OF LASER USED: Co 2 Laser Nd : YAG Laser ADVANTAGES more sofasticated , produces no heat thereby, least necrosis. no past operative dressing is required.

45. Any question