Periodontal therapy is directed at disease prevention, slowing or arresting disease progression, regenerating lost of periodontium, and maintaining achieved therapeutic objectives. A variety of different treatment techniques have been used including subgingival curettage, gingivectomy, modified Widman flap, and full- or split-thickness flap procedures with or without osseous recontouring. The best surgical approach remains controversial, although the results of longitudinal clinical trials has highlighted the advantages and disadvantages of each technique.

Curettage, scaling and root planing and modified Widman flap produced slightly better attachment level results, while pocket elimination procedures gave the greatest probing depth reduction.Surgical techniques included: gingivectomy, modified Widman flap with and without osseous recontouring, and apically positioned flap with and without osseous recontouring. All techniques halted loss of attachment, but the greatest gain of attachment was achieved when osseous resection was avoided and soft tissue was sutured to completely cover alveolar bone. No study to date has shown that plaque is the cause of periodontitis, but these studies certainly demonstrated that with no plaque there is no disease progression.

Indications for periodontal surgery

Nonsurgical therapy is performed prior to surgical treatment for periodontitis. Surgery is indicated where nonsurgical methods fail. In general, the success of nonsurgical treatment should be assessed following scaling and root planing but prior to the administration of antimicrobial agents or antibiotics.These medications tend to reduce inflammation and obscure sites where scaling and root planing has failed to resolve disease. Pocket reduction or elimination is not required in sites that respond to nonsurgical therapy and remain stable during maintenance. When surgery is required, however, shallower probing depths may be an appropriate goal to facilitate maintenance therapy and reduce the incidence of recurrence.

* Improved visualization of the root surface;* More accurate determination of prognosis;* Improved pocket reduction or elimination;* Improved regeneration of lost periodontal structures;* An improved environment for restorative dentistry;* Improved access for oral hygiene and supportive

periodontal treatment.

This procedure is used to excise suprabony pockets if there is sufficient attached gingiva, to reduce gingival overgrowth/hyperplasia, and for aesthetic crown lengthening in certain situations. Generally, this procedure should not be used when:

*Infrabony pockets/defects are present;

* osseous surgery is required;

* there is inadequate attached gingiva;

*frena/muscle attachments interfere;

*and long clinical crowns will compromise aesthetics.

A gingivectomy and gingivoplasty was used to correct gingival aberrations

A. Preoperative. B. Gingivectomy based upon aesthetic profile ratio.

C. Gingivoplasty. D. 8 weeks postsurgically.

*The word curettage is used in periodontics to mean scraping of the gingival wall of a periodontal pocket to remove inflamed soft tissues.*Curettage removes the soft tissue lining of the

periodontal pockets in order to completely eliminate bacteria and diseased tissue. It may be used along with scaling and root planing, but achieves a deeper and more complete cleaning. Evidence indicates, however, that it does not contribute any additional benefits beyond simple scaling and planing.*Inadvertant curettage:Some degree of curettage done

unintentionally when scaling and root planing is performed.

Presurgical curettage: used in patients whose treatment plans include strong evidence that a surgical phase will be used.Definitive curettage: No other therapy will be required or used.

Gracey Curettes: Used for eliminating the Soft Tissue Wall of the Periodontal PocketRATIONALEAccomplishes removal of chronically inflamed granulation tissue in the lateral wall of periodontal pocket.Apart from the usual components of angioblastic and fibroblastic proliferation in granulation tissue, may also contain pieces of dislodged calculus and bacterial colonies. 

INDICATIONS*Curettage can be performed in moderately deep infrabony pockets located in accessible areas where a type of ‘closed surgery’ is deemed advisable.*Done to reduce inflammation prior to pocket elimination using other methods or in patients in whom surgical techniques are contraindicated*Shrinkage of localized areas of gingiva, particularly interdental papillae which are bulbous and lead to plaque retention and accumulation *Curettage is frequently performed on recall visits as a method of maintenance treatment for areas of recurrent infection.CONTRAINDICATIONS*Presence of acute infection*Fibrous epithelial enlargement of gingiva as in phenytoin hyperplasia*Frenal pull on gingival margin*Extension of base of pocket apical to mucogingival junction.

PROCEDURE*Basic technique-curette is selected so that the cutting edge will be against the tissue.*Instrument is inserted so as to engage the inner lining of pocket wall and is carried along the soft tissue*Pocket wall maybe supported by gentle finger pressure on the external surface.

OTHER TECHNIQUESExcisional new attachment procedure(ENAP): Definitive subgingival curettage procedure.ENAP was an attempt to overcome some of the limitations of closed gingival curettage.Ultrasonic curettageUltrasonic vibrations disrupt tissue continuity, lift off epithelium and dismember collagen bundles.Effective for debriding the epithelial lining of periodontal pockets.It results in a narrow band of necrotic tissue(microcauterisation) which strips off the inner lining of the pocket

Also it is recommended while conducting closed curettage, to rinse the periodontal pocket with antiseptic solutions. Such procedure is called “one-time curettage”. Antiseptics that can be used:Chlorhecsidine 0,2%, peroxide hydrogeny 0,3%, Chloramini 0,5%.

*Caustic Drugs: To induce a chemical curettage of the lateral wall of the pocket*Drugs such as sodium sulfide, alkaline sodium

hypochlorite solution(antiformin) and phenol were used.*The extent of tissue destruction with these drugs

cannot be controlled and they may be increase rather than reduce the amount of tissue to be removed by enzymes and phagocytes.*LASERS – Laser curettage in suprabony pockets

where osseous surgery is not required.*When performed with mechanical root

instrumentation, it is considerably less invasive than traditional flap surgery.*Due to small size of fiber(ie)tip diameter,Nd:YAG

laser has been suggested as a good candidate for gingival curettage.

TISSUE RESPONSE TO CURETTAGE*Reversal of all signs of gingival inflammation. *Shrinkage, resolution of oedema and exudation.*Morphologic features in gingiva and mucosa are delineated more clearly after inflammation has been resolved.*Exuberant granulation tissue rarely present postoperatively.*Gingiva is firm to the scalpel and is of good texture to be beveled or split as required.

HEALING AFTER CURETTAGE*Blood clot fills the gingival sulcus which is totally or partially devoid of epithelal    lining. *Hemorrhage present in tissues, abundant PMNL’s apper shortly on wound surface.*Restoration and epithelialisation of sulcus generally requires from 2-7days.*Immature collagen fibres appear in 21days.*Zander and Waerhaug et al  reported that resulted in formation of long junctional epithileum.

CLINICAL APPEARANCE*Gingiva appears haemorrhage and bright red. *After 1 week, gingiva appears reduced in height owing to an apical shift in positon of gingival margin*After 2 weeks,with proper oral hygiene by patient, normal consistency and color of gingiva are attained and gingival margin well adapted to the tooth.*GINGIVAL  CURETTAGE – RELEVANCE*Gingival curettage and debridement of soft tissue wall of the pocket as an adjunct to SRP seems to offer no advantage in the initial healing response over SRP alone. *Removal vs non removal of granulation tissue during flap surgery and non surgical therapy (SRP) was studied by Lindhe & Nyman (1985). There results failed to show an advantage of granulation tissue removal.

*Studies provide  convincing evidence that SRP alone produce results clinically equivalent to curettage plus SRP.

*The various methods used for epithelial removal show that they have no advantage over mechanical instrumentation with curette.*Therefore gingival curettage by whatever method

performed should be considered as a procedure that has no additional benefit to SRP alone in treatment of chronic periodontitis.

Comparison between the results obtained in the initial preparation of the periodontal treatment such as oral hygiene and scaling and root planing and that of same procedure supplement by curettage, are made to assess the justification of using curettage to eliminate gingival inflammation and accomplish retraction of the gingiva.

One-time curettage: X-ray study

Due to the histological and clinical healing response investigated by current studies, the advantages of curettage in the shallow pocket are debatable. Curettage are now to be done in deep pocket, especially in the aggressive lesion such as that of the localized junvenile periodontitis. Nevertheless, there is insignificant difference between the result of the scaling and root planing alone and scaling and root planing with the tissue curettage.

One-time curettage: X-ray study

This procedure, introduced by Ramfjord & Nissle, was designed to remove the inflamed pocket wall, provide access for root debridement, and preserve the maximum amount of periodontal tissue. It is indicated where aesthetics is a primary concern, especially in the maxillary anterior sextant. The drawbacks include the inability to achieve pocket elimination and healing with a long junctional epithelium. (Open curettage)

After completing scalloped section, parallel to the gingival margin, and additional sections, partly movable muco-periosteal flap is shifted to the level of the alveolar ridge.Treatment of the teeth roots is carried out under visual control by curettes or ultrasonic instruments. Then the flap is adapted to the underlying tissues and stitched in the interdental spaces.

A modified Widman flap was used to reduce periodontal pockets around teeth # 12–15 (buccal and palatal view)

A, B. Preoperative. C, D. Incision

E, F. Flap reflection. G, H. Suture.

I, J. 1 week of healing. K, L. 8 weeks’ follow-up.

Histological studies have shown the flap procedures described above tend to heal with a long junctional epithelium and not a new connective tissue attachment. Long junctional epithelium, however, has been shown to provide a stable therapeutic outcome.

Historically the aims of periodontal surgery were to remove the soft tissue pocket wall and infected bone and to eliminate the periodontal pocket. Currently, the goals of surgery are to: 1) gain access for root preparation when nonsurgical methods are ineffective; 2) establish favorable gingival contours; 3) facilitate oral hygiene; 4) lengthen the clinical crown to facilitating adequate restorative procedures; and 5) regain lost periodontium using regenerative approaches. To ensure proper healing atraumatic surgical principles should be followed including: 1) adequate anesthesia; 2) surface disinfection; 3) sharp instrumentation; 4) minimal, atraumatic tissue handling; 5) short operating time; 6) preventing unnecessary contamination; and 7) proper suturing and dressing, if indicated.

Flap operationsThe formation of the flap and the types of sectionsThrowing soft tissue flap starts with the precise cuts. The location and direction of the cuts depends on the type of periodontal defect, purpose of surgical intervention and the desired result.The horizontal incision is made in all cases. itcan be intrasulcular (within the gingival sulcus) or paramarginal (parallel to the gingival margin, at some distance from it). In paramarginal section, connecting epithelium is excised, and gingival margin shifted in the apical direction. In this type of incision is the so-called latent gingivectomy. When viewed from the vestibular or lingual side, the paramarginal section has scalloped shape, close to the ideal form of the gingival margin.

If it is a wide interdental spaces, it is recommended a special flap that preserves gingival papillae (Takei et al, 1985). There is also a modification of this flap for narrow interdental spaces (Cortellini et al., 1995). Vertical sections are not always necessary or desirable, because they lead to the appearance of scars on the mucous membrane. If a vertical incision is required, it should be done in order to prevent gingival recession or loss of interdental papilla.

Horizontal sectionsA.traditional horizontal sections are performed from vestibular (red line) and the oral side (blue line). In interdental spaces, the surface of the tissue sections are arranged parallel or diagonally.B.Intrasulcular section at which epithelium of the pocket is not excised, but the maximum amount of soft tissue is saved.C.Paramarginal sections is performed at differentdistance from the gingival edge. Part of the tissue is excised by means of gingivectomy.

The flap that preserves thegingival papillae.

When suturing the wound after the operation, the soft tissue cover interdental spaces. However, this flap can be formed only at relatively wide interdental gaps.D. Papilla are displaced in the vestibular direction during the flap formation.E. Papilla are displaced in the oral direction.

Vertical sections and relaxing sections

Unfavorable location:A.If the cut goes through the papilla, there is risk of recession and loss of interdental papilla.B.The middle section is undesirablein the presence of vestibular pocket, as it increases the probability of gum recession.

The favorable location:C. The section at the side of midline does notleads to significant shrinkageand is better for healing.D. For the treatment of local defects it isrecommended a triangular flap, to unfold it ,two paramedial sections is conducted.

*Guided Tissue Regeneration. A more advanced technique, called guided tissue regeneration, is used to stimulate bone and gum tissue growth:*First, the root surfaces and diseased bone are

meticulously cleaned out. Preventing bacterial contamination is very important. The more residual bacteria, the greater the chance that the treatment will fail.*A specialized piece of fabric is sewn around the

tooth to cover the crater in the bone left after the cleaning. It is either absorbable or nonabsorbable. (Some studies report highly beneficial results with new absorbable materials, including those coated with the antibiotic doxycycline.)

*Bone Grafting. In some cases of severe bone loss, the surgeon may attempt to encourage regrowth and restoration of bone tissue that has been lost through the disease process. This involves bone grafting:*The surgeon places bone graft material into the defect.*The material may be either bone from the same patient or

a substance called decalcified freeze-dried bone allografts (DFDBA) which is obtained from a donor.*This material then stimulates new bone growth in the area.*Enamel Matrix Protein Derivative. Amelogenin is a

derivative of a major protein in the structure (the matrix) of enamel that helps stimulate gum tissue growth. A gel containing amelogenin (Emdogain) is applied during surgery and forms a coat over the roots of the teeth. The gel itself dissolves after 2 days, leaving the active substance behind. Studies report that it is safe and may significantly reduce the effects of periodontal disease. A 2001 study suggested that the benefits, as indicated by bone attachment, can persist for at least 4 years. (Results were similar to guided tissue regeneration.)

The risks of surgery include pain, swelling, blood loss, reaction to medications, and infection. Other potential risks include root sensitivity, flap sloughing, root resorption or ankylosis, some loss of alveolar crest, flap perforation, abscess formation, and irregular gingival contours. If post-operative complications occur, they should be managed by prompt and appropriate treatment, which may include control of bleeding, adequate analgesics or antibiotics.Post-surgery discomfort is usually managed easily with over-the-counter medications such as ibuprofen. If discomfort is severe, stronger analgesics may be prescribed. Some patients experience sensitivity to hot or cold temperatures from exposed roots. These problems can be managed with topical fluoride treatments or, in severe cases, with dental restoration.