Gingivectomy means excision of the gingiva.

By doing so, it provides visibility and accessability for complete removal of deposits and smoothening of the roots. Thus, creating a favorable environment for gengival healing and restoration of a physiologic gingival contour.

Gingivectomy was the treatment of choice. With the widened knowledge of healing mechanisms, sophisticated flap methods have replaced the procedure of gingivectomy.

INDICATIONS

Elimination of firm and fibrotic pseudo pockets.

Elimination of gingival pockets.

Elimination of suprabony periodontal access.

CONTRA-INDICATONS

Need for bone surgery, or assessing the bone shape and morphology.

If the bottom of the pocket is apical to the Mucogingival Junction.

In esthetic zones, particularly in the anterior maxilla.

TECHNIQUES

Surgical Gingivectomy

The pockets on each surface are explored with a periodontal probe and marked with a pocket marker. Periodontal lines are used for the incission of the facial and lingual surface of the tooth. The incission is started appical to the points starting the marking the course of the pockets and is directed coronally to a point between the base of the pocket and the crest of the bone. The incision should be placed as close to the bone, without exposing it. The incision should be beveled at approximately 45 degres to the tooth surface and should recreate a normal festoone patern of the gingiva.

The tissue is excised , the area is irrigated and the root surface is closely examined for any calculus deposits, root caries. The granulation tissue is carefully curetted, leaving the tooth surface clean and smooth. The area is covered with a surgical path.

Gingivectomy by Electro surgery

Technique

It is performed with the needle electrode, supplemented by the small, ovoid, loop or the diamond shaped electrodes foe festooning. a blending, cutting and coagulating current is used. for all reshaping procedure  the electrode is activated and moved in a precise shaving motion.

For hemostasis, the ball electrode is used.

Hemorrage must be controlled with direct pressure, then the surface is very lightly touched with a coagulating current.

Advantages

Electrosurgery permits an adequate contouring of the tissue and controls hemorrage.

Disadvantages-  Cannot be used in patients who have poorly shielded cardiac pacemakers.

The treatment gives out an unpleasant odor.

If the electrosurgery touches the bone it cause irrepairable damage. The heat generated can cause tissue damage and loss of periodontal support.

If it touches the root surface semental burns are produced.

Laser Gingivectomy

The most common lasers used in gingivectomy are the carbondioxide lasers and the neodymium:yttrium-aluminum-garnet, which have wave lenghts of 10600nm and 1064nm respectively in the nm range. The carbon dioxide laser has been used for the excision of gingival growths, although healing is delayed compared with healing after surgical gingivectomy.

Precautionary measures to avoid reflecting the laser beam on instrument surfaces which could result in injury to neighbouring tissue and eyes of the operator needs to be taken.

Gingivectomy by Chemosurgery

Chemicals such as 5% paraformaldehyde or potassium hydroxide have been described in the past but not used currently.

Disadvantages- the death of action cannot be controled hence the damage the underlying tissues. Gingival remodeling cannot be accomplished effectively.

Epithelialization and reformation of the attachment apparatus of the tooth is very slow comparedto the surgical mortality.

CONCLUSION

Though the gingivectomy procedure has a long history in the periodontal surgery, it has very less use in the current surgical scenario.

Ultrasonic Scaling has been used in Periodontal therapy, to a large extent. Though, very simple to use, there are certain guidelines to be followed, for achieving optimum results.

Ignorance to follow them, can have a negative impact, not only on the health of the patient, but also the operator.

Following are the drawbacks of the ultrasonic scaling,

The use of ultrasonic scaler will produce an increase in temperature & this heating may be due to

1. Functional heating due to contact between scaler & tooth.
2. Direct temperature application by the irrigation fluid.
3. Acoustic energy absorption of ultrasound transmitted into the tooth.

Thermal effects on dental pulp –

Use of coolant while scaling, is mandatory. Performing ultrasonic scaling without irrigation, leads to increase in temperature, and completely damage the pulp tissue. the coolant,  flow rate should be in the region of a least 20-30ml/min.

Thermal effects on the Periodontium –

The potential effects of ultrasonic scaling has been researched. Very little evidence has been documented, about the impact of scaling on the surrounding tooth supporting tissues.

Vibrational hazards to the patient –

Vibrating a wire at an ultrasonic frequency will potentially damage erythrocytes, leukocytes & platelets. Blood platelets are sensitive to sheer stresses & such forces are produced by the occurrence of acoustic micro streaming around an ultrasonically oscillating wire.

Vibrational hazards to the operator –

The vibrational amplitude associated with dental scalers is small but may still have the potential to produce “white finger”.

It was found that response time to stimuli on fingers was higher in technicians implying nerve or receptor dysfunction. It also revealed damage to myelinated & unmyelinated fibers in the fingers of the technicians.

Aerosol –

Ultrasonic scalers are known to produce aerosols and these aerosols are often produced from areas of significant disease activity including bleeding.

Aerosol formation can occur when the ultrasonic scaler tip comes in contact with fluids. Whether the fluid is saliva, blood or water the energy transmitted to the fluid is enough to produce the aerosol suspension of fine liquid particles.

This fine aerosol mist may remain airborne for extended periods of time, contaminating large areas of the dental operatory and challenging the filtration capacity of the mask.

Due to aerosol produced by mechanical scalers any high-risk infective patients should be treated with hand instruments.

Auditory –

Ultrasonic scalers may be a potential hazard to the auditory system of both clinicians and patients. Damage to operator hearing is possible through airborne sub harmonics of the ultrasonic scaler.

For the patient, damage can occur through the transmission of ultrasound through tooth contact through the inner ear via the bones of the skull.

Tinnitus is an early sign of hearing loss & may occur following ultrasonic scaling.

The ultrasonic scaler has been shown to cause no permanent harm to hearing through airborne noise. Transmission of ultrasound through the bone may potentially damage the inner ear, although this has not been demonstrated.

Cardiac Pacemakers –

Cardiac pacemakers are used to artificially stimulate the heart when the normal heart rhythm is either permanently or intermittently disturbed.

It is well known that magnetic, electrical or electromagnetic fields of sufficient strength can interfere with the action of a pacemaker. The handpiece of the ultrasonic scaler produces an electromagnetic filed and the severity of interference is dependent on the strength of this field.

The treatment plan for any Periodontal disease, starts with the PHASE-I Therapy, otherwise called Etiotrophic Phase. A thorough mechanical debridement, by Scaling and Root planing forms an integral part of this initial phase of therapy.

The advent of Power driven instruments, has proven to be a blessing for both the clinician and the patient, owing to its ease of use.

Though it is designed so as to make it least technique sensitive, there are certain guidelines to e followed.

Unit Preparation

The unit is assembled according to the manufacturer’s directions. The water lines of the unit should be flushed for no less than 2 minutes to reduce the microbial life that can exist within the dental unit’s water line. Bleeding the water lines for an additional 3 minutes will eliminate bubbles and reduce heat.

Thoroughly wipe the ultrasonic unit with a disinfectant use a sterile autoclavable handpiece or wipe the handpiece with disinfectant. Cover the unit and the handpiece with plastic or latex barriers.

The appropriate ultrasonic tip is selected and inserted into the handpiece. Once the tip is securely in place, the power & water settings are selected. The setting chosen should be low yet effective for the type of debridement to be completed. The water flow should be adjusted so that a mist of water surrounds the tip.

Patient Preparation

The patient’s health history should be reviewed to alert the clinician to any contra indications to the procedure. The procedure should be fully explained to the patient, and the patient should be asked to rinse with an antimicrobial mouth rinse. This reduces the bacterial load, and reduces the bacteremia created in the patient’s mouth during ultrasonic use. Patients should also wear safety glasses to protect their eyes from splattered debris. A fluid resistant drape can be used to protect the patient clothing from the water spray.

Suction, either high velocity evacuation or saliva ejector should be placed for elimination of water created by the ultrasonic unit.

Patients and operator positioning

Patient and operator positioning for sonic and ultrasonic instrumentation follow the same principles as for hand instrumentation.

For instrumentation of the upper arch, the patient is seated in a supine position with the chin slightly lifted up. The backrest of the dental chain should be approximately 45⁰angulation to the floor, if treatment is carried out in the mandible. A slight lowering of the patients chin allows good visibility to the lingual aspects of the lower front teeth. Good patient positioning should allow the operator to be seated upright. Whenever necessary, indirect view or illumination by the use of dental mirror should be used.

Site evaluation

Before each scaling procedure, the clinician should carry out a thorough evaluation of the sites to be treated,

-  Probing pocket depth

-  Root surface anatomy and morphology

-  Interpretation of radiographic findings.

In combination with detailed anatomic knowledge, the operator should be able to develop a 3 dimensional picture of the periodontal pocket therapy.

Instrumental grasp and finger rest

To allow maximum instrument stabilization the instrument hand piece should be held using a modified pen grasp.

An intra oral finger rest is recommended for instrumentation of teeth in the lower arch and in the upper front segment. An extraoral palm rest should be chosen while instrumenting maxillary posterior teeth, with the back of the hand in the right maxillary area or with the palm of the hand in the left arch respectively.

Adaptation

The tip of the ultrasonic scaler is adapted to the tooth at approximately 10-15 degrees, angulation greater than 15 degrees can cause the tip to be positioned incorrectly and damage could result to the tooth surface.

In case of tips with left and right offset angulation, tip is inserted such that convex working surface is in contact with root surface.

Using the concave side as working surface bears the risk that the instrument tip will be applied perpendicular to the root surface leading to unnecessary gauging and root surface damage.

Instrumentation of maxillary teeth

The left bent tip is used for the instrumentation of the maxillary front teeth palatal aspect and the maxillary left palatal aspect. In addition, the contra lateral approximal tooth surfaces may be cleaned with the same left offset tip inserted in an almost oblique / horizontal position.

The right offset tip is used to instrument the remaining areas to be treated.

Instrumentation of mandibular teeth

For instrumentation in the mandible the left offset tip should be used for the right lingual molar area, the lower buccal frontal segment and the lower left buccal posterior area.

As in the maxilla, the right bent tip is used for the instrumentation of the corresponding sites remaining to be treated.

By using the systematic approach, a complete and efficient instrumentation of the entire dentition is attainable and both patient and operator will benefit from the use of sonic and ultrasonic scaler.

Activation

Ultrasonic instrumentation is accomplished with a light touch and light pressure, keeping the tip parallel to the tooth surface and constantly in motion.

Leaving the tip in one place for too long or using the point of the tip against the tooth can lead to gouging & roughening of the root surface or overheating of the tooth.

Using a lower power setting and applying only slight pressure reduces the volume & depth of tooth structure removed.

The working end of the ultrasonic instrument must come in contact with the calculus deposit to fracture & remove it. As with hand instruments, instrument adaptation to the tooth is critical to success. The working tip must contact all aspects of the root surface to thoroughly remove plaque & toxins.

Although as much as 10 mm or more of the length of the ultrasonic tip vibrates, only a small portion of it can be adapted to contact the curved root surface at any one time or point.

As with hand instruments, a series of rapid, overlapping strokes must be activated to ensure complete root coverage. However, the rapid, light strokes with a blunt, vibrating working end impair tactile sensitivity & the constant water spray necessary for the operation of the instrument hampers visibility for these reason, during ultrasonic instrumentation. The tooth surface should be frequently examined with an explorer to evaluate the completeness of debridement.

Evaluation

The response of the soft tissue to debridement is the best indicator of successful treatment. In addition, the surface must be evaluated for complete deposit removal. Clinicians may need to follow ultrasonic scaling with hand instrumentation to complete the debridement process.

Infection Control

Ultrasonic & sonic scalers produce an aerosol hence particular precautions are necessary when using these devices to avoid inhalation or direct contact with blood borne & air borne pathogens.

The dental team should be wearing well-fitting disposable mask at 95% filtration of particles, 3-5μm in size. Because aerosols from ultrasonic scalers can remain suspended in the air for up to 30 mins masks should be changed every 20 mins during instrumentation. This is recommended since moisture seeps in the mask & decreases efficacy.

The aim of Periodontal treatment is to disrupt dental tartar or calculus, and subgingival biofilms, which act as reservoirs of periodontal pathogens, which can also cause bad breath or halitosis. Traditionally, to accomplish this, hand  instruments have been used for root debridement. Use of hand instruments, is technically demanding, time consuming, tiring, and uncomfortable for both the operator and  the patient. Keeping this in mind, many Power driven instruments have been devised since the last few decades.

Until recently, their use was mostly limited to supragingival debridement due to bulky working tips. Technologic advances and new designs of ultrasonic & sonic scalers have  transformed the role of power driven oscillating instruments in periodontal therapy.

TYPES of Dental Scalers

Power driven instruments, is further divided into 2 types, depending on the manner in which electric energy is converted into ultrasonic energy.

1. Ultrasonic : further divided, into

a. Magnetostrictive –

They are either driven by a metal stack consisting of nickel iron alloy strips or a ferrite insert inserted in handpiece.

Inside the handpiece a live coil generates an alternating electro magnetic field that leads to expansion or contraction of the ferromagnetic material. The resulting vibrations are conducted to the scaler tip, causing oscillations with amplitude of 13-72 µm and an elliptical motion pattern at frequencies of 20,000 H_z to 45,000 H_z.

Thus depending on the angulation of the scaler tip in relation to the root surface a more or less pronounced hammering on scrapping motion pattern will result.

b. Piezoelectric  -

Works on the principle of reverse piezoelectric effect, according to which, a quartz crystal changes dimension on application of electric potential.

The vibration is generated by changes in the dimension of a quartz crystal caused by the application of alternating current. The resulting oscillation mode of the piezoelectric scaler tip is strictly linear with amplitude up to 72 µm. Oscillate with frequencies of 20,000 – 45,000 H_z.

The mode of action of the tip is either of a tapping or scrapping nature, depending on the direction of the scaler tip towards the root surface.

The operator can adjust instrument power setting of the Magnetostrictive & Piezoelectric Ultrasonic scaler. Higher power setting increases the amplitude of tip oscillation, however with a constant & stable tip oscillation frequency motion pattern.

2. Sonic :

Sonic scalers operate by compressed air from the dental unit. A rotary cam within the handpiece generates vibrations with frequencies in the range of 6000 H_z to 9000 H_z. The sonic handpiece consists of a hollow rod, a rotor, and several rubber “O” rings. The compressed air is forced through the hollow rod. The rotor is a 6 mm wide ring that surrounds the hollow round above a series of angled holes present on the hollow rod. The air forced through the rod escapes through these holes and causes the rotor to vibrate, which in turn vibrates the hollow rod.

The vibrations are conducted to a scaler tip, which then oscillates, depending on the air pressure input, with an amplitude upto 1000 µm in an almost circular motion.

Due to this oscillation pattern, irrespective of the adaptation of the tip o the root surface (i.e. mesial, distal or buccal) plaque & calculus are removed by a tapping motion, which is one of the major advantages of the Sonic scalers over the Ultrasonic.

USES of Scalers

1. Supra and subgingival calculus.
2. Tenacious or heavy extrinsic stains.
3. Necrotic root Tissue
4. Overhanging amalgam margins
5. Orthodontic cement after band placement or removal.

CONTRAINDICATIONS

1. Patients with infectious disease.
2. On resin restorative materials
3. Cardiac pacemakers.
4. Young children
5. Dimineralized tooth structure
6. Immuno compromised patients
7. Metal tips on titanium implants

ADVANTAGES of Sonic and Ultrasonic Scalers

1. Greater access for debridement of grade II and III furcations
2. Can be used in static position
3. Use with a light touch, does not require a firm finger rest
4. Irrigation of pocket simultaneously
5. Washed field visibility
6. Increased patient comfort & acceptance.
7. Less tiring for the operator.
8. Scaling can be done in reduced time
9. Less tissue manipulation
10. Instruments do not need sharpening

DISADVANTAGES of Ultrasonic Scalers

1. Less tactile sense of root surface
2. Produce microscopic rippling of root surface
3. Requires high speed evacuation
4. Produces contaminated aerosol
5. Risks to patients or operators with Cardiac pacemaker
6. Expensive
7. Less Portable
8. Temperature of coolant may be source of discomfort to patients with hypersensitive teeth

In the course of disease, the mucosal tissues can assume a variety of discoloration.  Blue, Black and Brown discoloration constitute the pigmented lesions of oral mucosa.

The distributions of these various pigments in oral mucosa are quite variable, ranging from a localized patch to broad diffuse.  The specific coloration, tint, location, multiplicity, size and configuration of the pigmented lesions are of diagnostic importance.

FACTORS AFFECTING THE COLOR OF THE GINGIVA

• Chronic Inflammation:

The gingiva becomes red when there is an increase vascularisation or the degree of epithelial keratinization becomes reduced or disappears. The color becomes more pale when vascularisation is reduced or epithelial keratinization increases. So it gives red and bluish red color.

• Acute Inflammation

Color changes are more marginal, diffuse or patch like depending upon underlying acute condition. In Ulcerative Gingivitis, it is seen as marginal involvement.  In Hepatic Gingivostomatitis it is of diffuse type. In acute reactions to chemical irritation it represents as patch like or diffuses type. Initially there is red erythema; in severe acute inflammation the red colour gradually becomes a dull whitish gray.

• Metallic pigmentation
• Addison’s disease
• Peutz-Jeghers Syndrome
• Albright syndrome

TYPES

Two classes of pigments are observed,

Endogenous - Haemoglobin

Melanin

Hemosidrin

Exogenous - Silver Amalgam

Graphite

Lead, Mercury, Bismuth

Chromogenic bacteria.

METHODS OF DEPIGMENTATION

The saturation of melanin pigments can causes unesthetic dark gingival display.  This looks even more unesthetic in people with fair skin and high lip lines.   The pigmentation usually occurs in diffuse patches.  But sometimes a continuous pattern can be seen.

Surgical Technique

Following techniques can be performed.

1. Gingivo-abrasion technique.
2. Split thickness epithelial excision.
3. Combination of abrasion a split thickness epithelial excision.

Gingivo-abrasion technique -

Simple and effective technique. A medium grit football shaped diamond bur is used at high speeds on the epithelium to denude it. Care should be taken not to abrade the periosteum. The pressure used with the diamond should be minimal and copious irrigation is recommended. Hand instruments with a circular cutting edge may also be used. A periodontal pack is then placed over the denuded epithelium.

Split thickness epithelial excision -

A split thickness tissue of epithelium is removal on the attached port of the mucosa. A circumferential incision involving the entire pigmented area is made.

Combination technique -

In case where pigments are present very close to marginal gingiva and where the gingival pattern has areas of depressions and elevation on the facial aspect a combination technique is advised. Gingiva abrasion is used near marginal gingiva and area whole a split excision is difficult. A split thickness gingival excision is then performed to remove the remaining pigmented epithelium.

Free gingival grafts

Cryosurgical Depigmentation

Lasers -

Various laser techniques for ablation of cutaneous pigmented lesion and oral lesion has been advocated. Among them are,

1. Ruby lasers
2. Dye lasers
3. Nd:Yag lasers (Neomymium dimeium yatrium aluminum Garnet laser)
4. Alexandrite
5. Excimer lasers.
6. Co₂ lasers.

Any treatment intended for ablation of melanin should be non-scarring, safe, easy to handle, simple to apply, leave no melanin remnants and carry a low risk of repigmentation. With these conditions in mind CO₂ (carbon dioxide) laser, which is used extensively in oral and cutaneous surgery, was tested for it’s used in this condition.

CONCLUSION

Oral pigmentation may be focal, diffuse or multifocal.  They may be blue, purple, brown, gray or black. Some of them harbor of internal disease and some are localized harmless accumulations of melanin, hemosiderin or exogenous metal, but some can be highly lethal.  Biopsy is helpful aid to diagnosis for localized lesions; the more diffuse lesions will require thorough history procurement and laboratory studies in order to arrive at a definitive diagnosis.

The main objective to the depigmentation surgery is to remove the epithelium leaving the connective tissue intact. The healing brings about a change is color of the new epithelial tissue. Looks pink and bring differences in the smile. However over a period of time pigments redeposit in the epithelium.

Bone loss has been classified as either horizontal or vertical. Horizontal bone loss generally results as a relative thickening of the marginal alveolar bone. The effect of this thickening and the develpoment of vertical defects leave the alveolar bone with countless combinations of bony shapes. In order to alter these bony changes, a method of recontouring must be followed.

Osseous surgery may be defined as the procedure by which changes in the avular bone can be accomplished to rid it off deformities induced by gum disease or other relative factors such as bony exostosis and tooth supraeruption.

Osseous surgery can be either Additive or Subtractive in nature.

Additive osseous surgery- It implies regeneration of lost bone and reestablishment of the periodontal ligament, gengival fibres and junctional epithelium at a more functional level.

Subtractive osseous surgery- It is designed to restore the form of pre existing avular bone to the level present at the time of surgery or slightly appical.

TERMINOLOGY

Procedures used to correct osseous defects are classified  in two groups,

Osteoplasty- It refers to reshaping the bone without removing tooth supporting bone.

Ostectomy- This includes removal of tooth supporting bone.

Osseous form is said to be ideal when the bone is consistently more coronal on the interproximal surfaces than the facial and lingual surfaces.

RATIONALE

Osseous resective surgery follows a series of guidelines for proper contouring of avular bone and subsequent management of the over-lined gengival soft tissues.

More than any other surgical technique, osseous resective surgery is performed at the bony tissue and attachment level. Hence its value as a surgical technique is limited.

The goal of the osseous resective therapy is to reshape the marginal bone to resemble that of the unbalanced alvular process.

The technique is performed in combination with apically positioned flaps and the procedure eliminates periodontal pocket deaths and the tissue contour, so as to make patients oral hygiene maintenance easier.

TECHNIQUE

Instrumentation

A number of hand and rotary instruments have been commonly used for resective osseous surgery.

Rotary instruments are useful for osteoplasty whereas hand instruments provide more safety with ostectomy procedures.

Following are the sequential steps that need to be followe to perform resective osseous surgery.

Vertical grooving- this is designed to reduce the thickness of alveolar housing and provide more prominence to thye radicular aspects of the teeth.

It is the first step of the process, because it can define the general thicknes and subsequent form of the alveolar bone. It is performed using rotary instruments such as round carbide or diamond burs.

It should be avoided in areas with closed roots or thin alveolar housing.

Radicular blending- this is the second step of the process, and an extention to vertical groovig. It is an attempt to gardulise the bone over the entire root surface.

This step is not necessary if vertical grooving is very minor or if the radical bone is thin.

Both these procedures compose the bulb of resective osseous surgery.

Flattening interproximal bone- It requires the removal of very small amount of supporting bones. It is indicated when the interproximal bone levels vary horizontally.

It is best used in defects that have a coronally placed 1 walled edge of a predominantly 3 walled angular defect, and it can be helpful in obtaining good flap closure and improved healing.

Gradualizing marginal bone- this is the final step in the resective procedure. Bone removal is minimal but necessary to provide a sound regular base for the gingival tissue to follow.

FLAP PLACEMENT AND CLOSURE

After performing the osseous resection ,the tissue flap edges are replaced to their original position to cover the new bony margin or they may be positioned apically.

Positioning the bone apically to expose the marginal bone is one method of altering the width of gingiva. However it results in more post surgical bone resorption and patient discomfort.

Suturing may be accomplished using various suture materials and sutured knots.

Care should be taken, to place the sutures such that ther is minimal tension on the flaps wich could lead for their separation.

POST OPERATIVE MAINTENANCE

After suture removal, the surgical site is examined.

The patient is provided with post surgical maintenance instructions to maintain the surcal site plaque free.

Healing should proceed uneventfully in 14 to 21 days.

Maturation and remodelling can continue for upto 6 months. It is usually advisable to wait for atleast 6 weeks post healing of the surgical areas before beginning with dental restorations.

CONCLUSION

Although osseous surgical technique cannot be applied to every bony defect, but when properly performed it helps in achieving a physiologic architecture of marginal alveolar bone conducive to gingival flap adaptation with minimal pocket probing depth.

Hence resective osseous surgery is an important technique to provide a maintenable periodontial for periodontal patients.

Although periodontal disease is an infectious disease of the gengival tissue, changes in the bone are crucial because bone destruction eventually leads to tooth loss.

The height and density of the aveolar bone is maintained by a balance between bone formation and bone destruction.

DIFFERENT PATTERNS OF BONE DEFECTS SEEN IN PERIODONTAL DISEASE

Different types of bone deformities can result from periodontal disease. They can be easily detected on radiograph, but careful probing and surgical exposure of the areas are needed to confirm the exact dimensions.

Horizontal Bone Loss

It is the most common bone loss pattern seen in periodontitis.

The bone level is reduced, but the bony margins remain perpendicular to the tooth surface.

The facial and lingual bony plates, and the interdental septa are affected but not necessarily to an equal degree around the same tooth.

Vertical or angular defects

They occur in an oblique direction leaving a trough along side the root.

The base of the defect is located apical to the surrounding bone.

They are classified on the basis of the no. of osseous walls absent.

They are called as 1,2 3 walled defects.

The 3 walled angular defect is also called a hemiseptal defect which indicates the presence of 1 bony wall. Such defects ensure poor prognosis.

Osseous Craters

These are concavities in the crest of the interdental bone confined within the facial and lingual walls.

Commonly seen in mandibular posterior segments.

Bulbous bone contours

These are bony enlargments caused by exostoses, adaptation ta funtion by tressing bone formation, found more frequently in the maxilla.

Reversed architecture

Produced by loss of intedental bones including facial and lingual plates and excluding loss of radicular bones

This leads to reversing the bony architecture.

Commonly seen in the maxilla.

Ledges

These are plateau like bony margins caused by resorption of thickend bony plates.

Furcation involvement

This refers to the invasion of the bifurcation and trifurcation of multi rooted teeth by periodontal disease.

Furcation involvements can be classified as GradesI,II,III,IV depending on the amount of tissue destruction.

The word curettage means the scraping of the diseased gengival wall of a periodontal pocket to separate disease soft tissue. It consist of the removal of the inflamed soft tissue, lateral to the periodontal pocket wall. Performed in shallow pockets, with the objective of causing tissue shrinkage.

It is different from subgingival curettage. The latter is performed apical to epithelial attachment, upto to the alveolar crest. This is performed in deeper pockets.

RATIONALE

Curettage accomplishes removal of the pathological granulation tissue that forms the lateral walls of the periodontal pocket.

This tissue also contains dislodged calculus deposits and bacterial colonies which would interfere with the normal wound healing process.

INDICATIONS

Indications for curettage are very limited, and can be used after scaling and root planing for the following purposes,

Curettage can be performed in moderately deep intrabony pockets in accessible ares where a close surgery is advisable.

The clinician should opt for this approach, only when other surgical techniques cannot be performed.

Curettage is also frequently performed on recall visits as a miantenance treatment modality.

BASIC TECHNIQUE

The basic periodontal therapy, which is scaling and root planing is performed before gingival curettage.

Administration of local anesthesia is required.

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The curette is selected such that its cuttin edge will be against the soft tissue. (eg: Gracey# 13-14 for mesial surfaces, Gracy # 11-12 for distal surfaces)

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The instrument is inserted so as to engage the inner lining of the pocket wall and is smoothly swept in one single horizontal slope.

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The pocket wall should always be supported gently by a finger pressure on the external surface.

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The area is flushed to remove debris and the tissue is partly adapted to the tooth surface using gentle finger pressure.

OTHER TECHNIQUES

Excisional New Attachment Procedure (ENAP)

After adequate anesthesia, an internal bevel incision from the margin of the free gIngiva apically to a point below the bottom of the pocket is made.

The aim of this incision is to cut  the inner portion of the soft tissue wall of the pocket all around the teeth.

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After excising the tissue, the exposed cementum is carefully root planned to achieve a smooth surface.

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Approximate the wound edges: in case they do not meet passively, recontouring the underlying bone for proper adaptation will be required.

Ultrasonic Curettage

Ultrasonic vibrations disrupt the tissue continuity, and lifts of the epithelium.

It is effective for debriding the epithelial lining of the periodontal pocket and results in a narrow band of nacrotic tissue which can be removed.

The Morse scaler – shaped and rod -shaped ultrasonic instruments are used for this purpose.

Caustic Drugs

Drug such as sodium sulfide, antiformin and Phenol have been proposed for this purpose in the past.

The extent of tissue destruction with these drugs cannot be controlled and may increase the amount of tissue to be removed. Owing to this effect use of caustic drugs is obsolete.

The development of a significant horizontal component to one or more furcations of a multi rooted teeth or the development of a vertical component to the furca post additional problems.

Such advanced lesions do not respond to conservative periodontal treatment modalities.

SURGICAL OPTIONS

Root Resection

Indicated in multi rooted teeth with grade II to IV  furcation involvement.

It is preferable to get the tooth  endodontically treated before resection of the root.

In general teeth planned for root resection include the following,

• Teeth of critical importance to overall dental treatment plan. For example, teeth serving as abutments for fixed or removeble restorations.
• Teeth that have sufficient remaining attachment for function.
• Molars with advance bone loss in the interproximal and interradicular zones, unless the lesions have three bony walls , are not candidates for root amputation.
• Teeth for which a more cost effective measure or therapy is unavailable. Eg. Teeth that have been endodontically treated successfully in the past but now present with a vertical root fracture, advanced bone loss, decay on the root surface.

WHICH ROOT TO REMOVE?

Remove the root that will eliminate the furcation and result in a maintenable architecture on the remaining roots.

Remove the roots with the greatest amount of bone and attachment loss.

Teeth with horizontal bone loss are poor candidates to undergo this procedure.

Remove the root that best contributes to the elimination of periodontal problems of adjacent teeth.

Remove the tooth with maximum anatomic problems like severe curvature, root flutings, developmental grooves.

Roots that ensure complication for future periodontal maintenace should be opted for resection.

Hemisection

Hemisection is the splitting of a multirooted tooth into two seperate portions.

Also called as bicuspidization or seperation.

Most likely to be performed on buccal and lingual class II or III furcation defects.

After seperation of the teeth 1 or both the tooths can be retained.

ROOT RESECTION/ HEMISECTION TECHNIQUE

Administration of local anesthesia.

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Full thickness mucoperiostal flaps elevated. The flap should provide adequate access for visualization and instrumentation of the furcation defect.

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Thorough debridement and complete exposure of the furcation on the root to be removed.

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In case of accessability problems, removal of a small portion of facial/ palatal bone may be required.

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A cut is then directed from apical to the contact point, through the tooth, and to the facial and distal orifices of the furcation, with a high speed surgical length fissure length carbide bur.

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In case of a vital root resection a more horizontal cut is preferred to an oblique one since it exposes less surface area of the radicular pulp chamber.

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This root stump can be removed by odontoplasty after the completion of the endodontic therapy.

While elevating the root from its socket care must be taken to avoid damage to the adjacent bone and roots.

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If necessary, the now visible furcation area can be treated to remove any plaque retentive areas.

For  hemisection a vertical cut is made faciolingually through the pulp chamber, and through the furcation.

If there is a metallic restoration in the surgical zone, it should be cut before the elevation of the flap. This prevents contamination of the surgical field with metallic particles.

RECONSTRUCTION

Furcation defects with significant three walled or two walled defects are ideal candidates for bone grafting, guided tissue regeneration procedures. these procedures are designed to induce either new attachment or reattachment in the defect area.

EXTRACTION

Extraction of teeth is the prefered treatment in a through and through furcation defects with advanced attachment loss in individuals who cannot or will not maintain oral hygiene.

Patient with high level of caries activity or who have other socio or economic factors should not undergo complex therapy.

CONCLUSION

The keys to long term success of furcation therapies appear to be,

• Thorough diagnosis
• Selection of co-operative and compliant patients,
• Carefully conducted restorative and surgical procedures.

The furcation is an area of complex anatomic morphology that may be difficult to access during routine gum disease treatment. It’s a term used to describe a defect that affects the base of the root trunk, that is either the bifurcation or trifurcation areas of the tooth root.

The presence of a furcation involvement leads to a diagnosis of advanced periodontitis.

CAUSES OF FURCATION ENVOLVEMENT

Bacterial plaque

Prolonged accumulation of plaque, leads to continuing inflammatory conditions, and eventual attachment loss, involving the tooth furcation area.

Local anatomic factors –

Root trunk length: This is the distance from the cementoenamel junction of the tooth to the entrance of the furcation.

Teeth with short root trunk may be more accessable to maintenance procedures.

Alternatively teeth with unusually long root trunks or fused roots show poor prognosis.

Root length: Teeth with long roots and short to moderate rot length are more readily treated.

Root form: The mesial root of most maticular first and second molars are typically curved distally in the apical third.

Such anatomic features results in an increase incidence of vertical root fractures.

Local  developmental anomalies-

Cervical Enamel Projection (CEP): Reported to occur on 8.6% to 28.6% of molars.

Commonly seen in mandibular and maxillary second molars.

Dental caries and pulpal death.

All these factors should be considered during the diagnosis, treatment planning, of the patient with furcation defects.

CLASSIFICATION

Grade I: This is an incipient or early stage of furcation envolvement. early bone loss may have occured with an increase in probing death but no radiographic changes are usually found.

Grade II: This furcation lesion is essentially a cul-de-sac  with a definite horizontal component.

A portion of the alveolar bone remains attached to the tooth, hence there is no communication between multiple defects.

Radiographs may or may not depict the furcation involvement.

Grade III: There is no bone attached to the dome of the furcation. The opening may be filled with soft tissue and may not be visible. The clinician may find it difficult to pass a periodontal probe through                           the defect due to interference of bony margins.

However,  if the sum total of the buccal and lingual probing dimension is equal to or greater than the buccal/lingual dimension of the tooth, the clinician can conclude that a grade III furcation                       defect exists.

Grade IV: In such a defect the interdental bone is destroyed and the soft tissues have receded apically so the furcation involvement is clinically visible.

A tunnel exists between the roots which permit the ready passage of a periodontal probe. (Nabers Probe)

TREATMENT

Why is furcation therapy necessary?

To facilitate maintenance.

To prevent further attachment loss along the root surface.

To obliterate the furcation defects as a periodontal hazard.

THERAPEUTIC CLASSES OF FURCATION DEFECTS

Class I :

Amenable to conservative periodontal rherapy.

Since the periodontal pocket has not entered the furcation area of the tooth, oral hygiene, scaling and root planing are effective.

In cases of thick over hanging margins of restorations, facial groves, or CEPs should be elimenated by odonto plasty, recontouring.

Resolution of inflammation and periodontal ligament repair are usually sufficient to restore periodontal health.

Class II

Shallow horizontal involvement without vertical bone loss response well to localized flap procedures with odontoplasty and osteoplasty.

Class II to IV:

Non surgical treatment is usually ineffective due to inaccessability.

Periodontal surgery, endodontic therapy and restoration of the tooth may be required to retain the tooth.

CONCLUSION

For many years the presence of significant furcation involvement meant a hopeless long term prognosis for the tooth. Clinical research however has indicated that furcation problems are not as severe a complication, and can well be treated.

All tissues undergo certain changes as a result of aging reduction in vascularity, elasticity & reparative capacity are some of the common manifestations of aging, generally noticed in tissue. Periodontal tissues are no exception to this rule and may show sign of atrophy as age advances.

EFFECT OF AGING ON ORAL TISSUES AND FUNCTION

• Dentition – With aging, teeth tend to change in appearance and structure, darkening or yellowing is commonly observed and results primarily from changes in the thickness and composition of the underlying dentin.

• Odontoloblasts continue to form secondary dentin throughout life, moving toward the pulp chamber but the characteristics of the material differ from those in primary dentin.
• Enamel abrasion and crystalline changes also contribute to the changes in tooth appearance. This continuing dentin production results in the progressively smaller pulp chamber and root canals. The number of blood vessels entering the tooth and the concentration of cells also appear to decrease with age. The capacity of pulp tissue to respond to trauma may thus decrease, whereas potential assays for endodontic treatment becomes restricted.

• Hydration- Hydration of the oral cavity with saliva is one of the most important processes of oral physiology. The roles of saliva include lubrication and protection of oral tissues, preparation of food for chewing and swallowing, initiation of the digestion process, facilitation of taste function, and preservation of a balanced population of the oral flora. It is essential for proper chewing, swallowing, taste and speech. The absence of saliva leads to rapid degradation of oral hard and soft tissue and bad breath. 

• Taste – the ability to taste substances placed in the mouth, gestation, may not change greatly with increasing age. The number of taste buds present on the tongue does not appear to decrease with age. Earlier reports, which once suggested gustatory loses with aging, frequently involved institutionalized subjects and thus may have reflected the influence of pathologic conditions. No broad, age related changes in ability to taste have been demonstrated.

EFFECTS OF AGING ON PERIODONTIUM–

1. Gingival Epithelium – According to Shklar, thinning and decreased keratinization of the gingival epithelium have been reported with age. This is opposite of gum overgrowth. This significance of these findings could mean an increase in epithelial permeability to bacterial antigen, a decreased resistance to functional trauma or both, which influence long term periodontal outcomes.

2. Gingival Connective Tissue – Increasing age results in coarser and more dense gingival connective tissue. Increased rate of conversion of soluble to insoluble collagen, increased mechanical strength and increased denaturing temperature. A greater collagen content has been found in the gingiva of older animals despite of lower rate of collagen synthesis.

3. Periodontal Ligament – The changes include

• Decreased no. of fibroblasts and a more irregular structure.
• Decreased organic matrix production and/ or epithelial cell rest and increased amount of elastic fiber.
• The principle fibres of periodontal ligaments are thick in aging humans than in younger individuals. The well organized bundles are broad and wavy.
• The interfibrillar areas are reduced in size. There is a decrease in the ratio of ground substance to collagen. Few fibroblasts, osteoblasts and cementoblasts can be found.
• The periodontal ligament shows degenerative hyaline changes.

4. Cementum – An increase in cementum width is a common finding. This increase may be 5 – 10 times with increasing age. The increase in cementum width is greater apically & lingually.

5. Alveolar Bone –  The alveolar bone proper has darkly stained margin which may be interpreted as aging characteristic of bone. Although age is a risk factor for the bone mass reduction in osteoporosis.

Osteoporosis has been reported in aging particularly in the alveolar bone of post menopausal women, but the decrease in trabeculation of alveolar bone some times seen on radiographs is more often related to loss of function.

EFFECT OF AGING ON RESPONSE TO PERIODONTAL TREATMENT–

The successful treatment of periodontitis requires both meticulous home care plaque control by the patient and meticulous supragingival and subgingival debridement by the therapist. Unfortunately only few studies that have directly compared such as approach among patient of different age groups.

Few studies have shown no difference in response to surgical or non surgical in older patients as compared to young ones. However if plaque control is not ideal continous loss of attachment is inevitable.

A biologic and physiologic review indicates that the effect of aging on structure of periodontium, function of the immune response and nature of either supragingival or subgingival plaque have a negligible impact on an individual experience of periodontal disease. Aging might affect the other aspect of managing the periodontal disease.

PRACTICAL GUIDELINES FOR PERIODONTAL MANAGEMENT OF OLDER ADULTS-

• The dentist can also expect the older adults to have atleast one chronic medical condition for which he or she is taking at least one prescription medication. A thorough medical and medication history is therefore essential. In many cases the dentist should consult with the patient’s physician. The clinician must also consider the patients mental, physical and socioeconomic status for example a patient may be depressed over the recent loss of a loved one. A fixed retirement income may take certain procedures difficult or impossible to afford. The dental professional must be sensitive to these issues but must not use them to prejudge the patient’s ability to undergo treatment.

• The dentist must distinguish between age and ageism when formulating a treatment plan. Ageism means that advance age is used as reason to deny needed treatment to the patient. This attitude is commonly used as why bother?… He is going to die soon any way…or I am sure she can’t afford it?  Age is per say is not a contraindication to any modality of periodontal treatment. Consideration of age associated factors such as physical frailty or confusion is a legitimate factor to consider when formulating a treatment plan. Ultimately the patient must decide on the course of treatment with guidance from the dentist.

• Surgical therapies, such as osseous surgery, flap surgery, guided tissue regeneration, osseous grafting, dental implants and implant supported dentures, should be used when indicated. Extraction should be recommended if the dentist believes that the patient is at risk for infection, decreased function or comfort, or loss of adjacent teeth. Age is not a contraindication for these therapies.

• Similar to all periodontal patients, older adults need regular supportive care. This care is especially important for patients whose ability to perform oral home care may be compromised by physical limitations. Regular appointments for supportive care, spaced 3 months apart, have been shown to be effective in preventing additional attachment loss & gingival inflammation.

CONCLUSION

Increasing age has been established as one of the risk factor for periodontal disease whether the risk is related to intrinsic changes resulting from aging or the consequences of earlier pathology untreated over a period of time is not completely understood. Anatomic changes in the periodontium that occur with aging have been reviewed by several investigators. The epithelium becomes thinner with decreased keratinization, collagen fibres become more coarse. Width of cementum increases, width of periodontal ligament decreases and principal fibres become more irregular, how these changes are related to clinical findings is not clear.