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Electrosurgical gingivoplasty
Periodontia ELECTROSURGICAL DEVON iM. SAGHIRIAN,
GINGIVOPLASTY
D.D.S.,” PHILADELPHIA,
PA.
Introduction fifteen years ago, Webb1 brought to the attention of the dental proSOME fession the use of electrocoagulation in the treatment of periodontal disease. His technique employed the bipolar, biterminal electrode, activated by a sparkgap type generator. The passage of high frequency current between the two poles of the active electrode produced internal heat, with the effect of instanElectrocoagulation was expounded and taneous coagulation of tissue protein. gained popularity, due to its simplicity and effectiveness. Clinical experience, however, soon revealed that this method had certain limitations. The deep penetration of heat could not be controlled and would occasionally result in destruction of healthy tissue as well. The substitution of the spark-gap current by the electronic current of the vacuum-tube generator somewhat improved the control factor, but, inasmuch as electrocoagulation was not sufficiently substantiated by experimentation and the test of time, it could not overcome the adverse publicity it had built up for itself, and indirectly for electrosurgery. While electrocoagulation was in the limelight, little attention had been given to the early investigators in the field who had associated themselves with the development of electrosurgerg. The application of high-frequency currents for cutting, coagulating, or desiccating has been done as far back as 1909 both in Europe and the United States. Most of these methods having originated in Germany were subsequently taken up and developed in various surgical fields by our medical pioneers: Wyeth, Clark, Kelly, and others. In dentistry Miiller” employed the wire loop electrode and reported its use in 1924. One of our early investigators in this field, Ogus, collaborating with Kelly, was experimenting with the cutting currents during this developmental stage. Ogus3 was introduced to electrosurgery in 1925 by Elmer Brown Clark of Trenton, New Jersey, who had seen the work of Clark in Philadelphia. sent Ogus to meet Kelly and Ward at Johns Hopkins University in Baltimore, Maryland. These eminent surgeons were using the high-frequency current in general surgery, utilizing it for deep coagulation and destruction of precancerIn 1940, Ogus was invited ous and cancerous masses, where this was indicated. to give a paper before the staff of Johns Hopkins University under the sponsorship of Professor Kelly and Professor Ward. Dr. Kelly was impressed by the Read before the Pennsylvania State Dental Society and the Odontological Society Western Pennsylvania, Pittsburgh. Pa.. June 2. 1949. *Associate in Stomatology, Graduate School of Medicke, University of Pennsylvania. 1549
of
1550
LEVON
$1. SAGHIRIAN
presentation and, in putting the stamp of approval on electrosurgcry for dentistry, expressed himself, “. . . I think it to be one of the most remarkable and practical discoveries in surgery? since I have come into the field back in the eighties of the last century.” This author’s interest was aroused independently in 1933 at the Graduate Hospital in Philadelphia, while observing the early use of high-frequency currents in the fields of dermatology, gynecology, proctology, and thoracology. Collaborating wit,h W. J. Johnson, then head of the Department of Physical Medicine, a number of clinical cases were treated with primitive spark-gap t,ype high frequency equipment available at that time. The brief popularity of elect,rocoagulation during this period and its apparent limitations react,ivated our interest in oral electrosurgery, more so when newer-designed electronic equipment was made available to us for experimentation. Early clinical research was directed to the resection of excess tissue, growths, changing of tissue attachments, and the incision and draina.ge of abscesses. It was in the field of periodontal surgery that, with the abundance of clinical material available, electrosurgery found wide use in pocket elimination and the molding of tissue. With the use of this new technique, it was apparent t,hat the close proximit? of the oral mucosa to alveolar bone and the dental structures, as well as other biologic factors peculiar to the mouth, necessitated the development of (a) the type of equipment best suited for our needs and (1)) a technique which would make electrosurgery reasonably safe and practical.
Electronics The science of electronics covers the emission of electrons t.hrough free space (vacuum) or through appropriate gases, as well as control of electrons under these conditions. It does not explain the behavior of electrons when flowing in solid conductors such as copper wire or tungsten electrodes. Radio and electronics, as a result of research and experimentation, from their inception have been closely relat,ed. Electronics is an offspring of radio. The Fleming valve (1903) and the De Forest hudion (1906) were t.he first “vacuum tubes” and as such mark the entrance of the electronic era. The Triode oscillator and t,he Triode amplifier, which came about 1912, were developments in tube circuit. and serve as oscillation generators and amplifiers of weak radio signals. The present, wide application of tubes and the science of electronics in radar, television, facsimile electronic emission, and high frequent> heating in industry is evidence of the success of this development. X distinction must be made between the types of machines used in surgery. They are : (I) the spark-gap type ; (2) the vacuum-tube type : and (3) the combinat,ion spark-gap and vacuum-tube type. The spud-gap type apparatus produces electrical waves of high frequency. The condenser, spark-gap, and resonator form the high-frequency oscillating The oscillations of the spark-gap machina are damped; they are not circuit. continuous but occur in separate oscillating periods, each consisting of a series
ELECTROSURGICAL
GINGIVOPLASTY
3551
The frequency of oscillations varies of rapidly decreasing oscillation trains. from 500,000 to 2,000,OOOper second. The spark-gap apparatus produces principally a current suitable for fine desiccation, fulguration, and heavy coagulation. The zmuwna-tube apparatus produces high-frequency oscillations of someMuch higher what different character than that of the spark-gap machine. The oscillations are damped ; they are continuous frequencies are produced. The frequencies vary between 10,000,000 and and have a uniform amplitude. 100,000,000 per second. The vacuum-tube apparatus is primarilv suited for fine cutting and coagulating. This type of apparatus may be modified by rectification and variance in tank coil and condensers to produce varying wave lengths and patterns, so that suitable fulgurating effects as well may be produced. Similarly, the spark-gap apparatus may be modified to produce satisfactory cutting effects. Combination ,~pa~li-g~~ and tube-t!ype machines are also available where a blended current is desired. The surgeon has a selection in the use of the sparkgap current, the vacuum-tube current, or a combination of the two in any proportion desired. These machines, being bulky, are more suitable for use in the hospital operating room. The dentist will find tire vacuum-tube apparatus compact and versatile for all oral electrosurgical procedures required in office use. F’undamental research in the science of electronics in various scientific and industrial fields has contributed to a better understanding of the behavior of high-frequency currents. Mouradian, Hummer, and Rawls’ applied this knowledge to engineering perfection in medical-surgical equipment. In our experiments we were further aided by engineering consultants in making the necessary modifications and in designing equipment of a standard of efficient>- which would serve our purpose. We have now at our disposal units with satisfactory range of wave lengths, patterns, and power which control the performance of delical-e electrodes of our own design. This knowledge has been coordinated with developmental research carried on in the clinic and in private practice for over fifteen years in order to arrive at a practical technique.
Definition of Electrosurgery Electrosurgery is the surgical use of electricity in one form or another. In the strictest sense of the term it covers all forms of endothermic applications on human tissue, as well as t,he use of the electrocautery, electrolysis, and other electrochemical means for the destruction of tissue. General modern usage, however, has restricted the term electrosurgery to the surgical applicat.ion of high-frequency electric currents. The surgeon must understancl current characteristics produced by various frequencies and wave patterns and must learn through experimentation how to control these currents before attempting to use electrosurgery. Electrosurgical methods are an adjunct to scalpel surgery. The principal effects produced are: (1) fi ne almost bloodless dissections by acusection; (2)
1552
LEvON
M , SBGHIRIAK
hemostasis and destruction of tissue by electrocoagulation ; (3) dehydration of surface lesions by fulguration or desiccation; (4) sterilization. These effects are interrelated, ant4 best results are produced by skillful combinations.
The Electrode The active electrode is sometimes called the cold cutting knife or the radio knife, because the electronic knife remains cold all through the operation and the heat generated in the tissues is always under the control of t,he operator. A coagulating or cutting current is produced, depending on the frequency, the wave pattern, the strength of the current, or the size and shape of the electrode. In contrast, the low-voltage electric current in the cautery functions only as a means of heating and maintaining the temperature of the instrument or electrode employed, much as a heated wire would. Searing or burning is produced by a red hot instrument ih contact with tissue.
Pocket Elimination Regardless of the method of choice, one thing is constant: periodontal disease cannot be cured or arrested unless the pathologic crevice is either closed or reduced to near zero. If we feel that reattachment of detached tissue is not feasible, then we must direct our attention to pocket elimination either by shrinkage or by resection. It is not the purpose of this report to discuss the relative merits of the two approaches to the same problem, pocket elimination. Both methods have their Undoubtedly, successful results are produced by either ardent advocates. means, In the final analysis, decision as to which one to use rests on the clinical judgment and experience of the operator. There is at present a well-established concept among periodontists that gingivoplasty is the direct approach to surgical, chemical, or electrosurgical pocket elimination. History records that surgery was attempted by the ancient Babylonians and Egyptians. Not only gum resections were practiced with sharp objects, but the hot poker also played its part for the destruction of diseased tissue. Surgical methods utilizing the knife are as old as the profession itself. They were described by Fauchard in 1746, Robiesek in 1862, and Riggs in 1867. Reports from Germany5 indicate that durin, 0 the last war period the dental profession in continental Europe followed the surgical trend and gingivectomy was practiced more extensively than in the United States. This perspective is is not being regarded now gaining headway in this country, and gingivoplasty only as the last resort, but an effective and practical means of pocket elimination in cases where a diagnosis would indicate prompt and certain eradication. In discussing pocket elimination by electrosurgery, it is the purpose of this report to deliberate not only on the advantages of this method but also on its possible harmful effects, through the use of inadequate equipment or faulty technique. Electrosurgery has many applications in dental practice. It lends itself particularly well to the treatment of chronic periodontal disease.
ELECTROSURGICAL
GINGIVOPLASTY
1553
Periodontosis We must bear in mind that periodontosis is a chronic degenerative disturbance and involves the destruction of the periodontal membrane and regressive is noninchanges in the supporting alveolar bone. The disease fundamentally flammatory in character, though it is seldom observed in an aseptic form. It occurs more often associated with periodontitis or hyperplasia. The etiology of this disease is often difficult to determine. It is assumed to be associated with, if not caused by, systemic dyscrasia. Periodontosis is not uncommon in the young, when it is related to a systemic dyscrasia, such as diabetes, endocrinopathic conditions, nutritional deficiencies, or to oral sepsis. However, in individuals past the age of 20 it is the most prevalent of human diseases including caries. More teeth are lost through this cause than any other. The sooner the disease is detected the sooner it can be arrested or cured. It is the duty of every dentist to educate the public in preventive dentistry. It is cowardly to ignore the treatment of periodontosis by simply labeling it incurable. Clinically, periodontosis characterizes itself with the existence of the pathologic pocket. The boundaries of this space are, on one side, the cementum of the tooth in whatever state of health it might be and, on the other side, the surface of the detached or excess tissue. The pathologic picture also involves the epithelial drift in advance of the pocket and bone resorption in the infiltrated area. In the presence of periodontitis the crevicular epithelium is ulcerated and the gingival corium inflammatory in character. The contents of this space may include debris, necrotic tissue, calculus, inflammatory granulation tissue, and an abundance of extravascular fluids and pus. The primary consideration in periodontosis is the extent of regressive changes that has taken place in the alveolar bone. The onset of periodontosis may be detected in advance, hefore vital tooth attachment is dangerously lost, by careful radiographic examinations, made periodically. Kaplan and Mann6 demonstrated conclusively that the elimination of the pocket will arrest the disease and make its cure possible, Healing is prompt following surgical and electrosurgical gingivoplasty. Soft tissue regenerates over the existing level of alveolar bone. Nature will smooth and round. alveolar bone as soon as the exciting symptoms are relieved and healing proceeds. Osteosis may heal completely if the process of regeneration by resorption and formation of bone proceeds undisturbed. Clinically, following pocket elimination the picture changes from the pathologic state to that of normal periodontal health which simulates a state of physiologic recession.
Osseous Resection It is not necessary, nor is it advisable, in practicing gingivoplasty to file or mutilate alveolar bone in any way, except in certain instances in which architectural requirements indicate it. These cases are fortunately in the minority RSpointed out by Schluger.? Elimination of periodontal disease by gingivoplasty should be attempted
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SAGHIRIAN
only where the teeth involved are firmly supported in bone. Where osteolysis has regressed to such a great extent that isolated deep intraosseous pockets exist, an additional problem presents itself. Whether or not deep bone pockets may close by regeneration with gingivectomy alone is a moot quest,ion. In certain selected cases b,one resection and reshaping are needed. These cases should be studied in advance by careful radiographic and clinical examination. They require special consideration, and any one of the following procedures may be indicated : 1. Removal of the contents of the space including all traces of necrotic cementum on the root surface. If it is possible to protect the blood clot against infection and irritation either by a flap operation or pack, then organization of connective tissue and later bone regeneration may be expected. The influence and other factors should be of the endocrine glands, vitamin D, vascularity, considered. 2. Reshaping t,he bone to conform with architectural requirements so that tissue will heal with deflecting contours. 3. Extra&ion of the tooth if much vital bone support has been lost or would have to be sacrificed. The cosmetic effects and postoperative hypersensitivity of denuded root surfaces should be considered. We may be confronted at times with the choice of losing the tooth or accepting an inevitable recession.
Gingivoplasty The purpose of gingival surgery is t,o eliminate pockets, mold tissues, and aid nature in restoring the periodontium to a physiologic state. In order to attain this goal it is necessary to remove pathologic and excess tissue, to remove the soft tissue side of pockets, and to produce deflecting contours and interproximal sluiceways. Methods of gingivoplasty are classified into the surgical, chemical, and electronic groups.8 Each will give sat,isfactory results when surgical principles are followed.
Electrosurgical
Techniques
The cardinal rule in regula,ting the strength of current is that one should always use the lowest strength that cuts freely to the desired depth, and one should choose the size and shape of electrode according to electrical resistance of tissue under the electronic knife. All incisions should be made bolcll~, without hesitation, and following a predetermined pattern. The use of heavy electrodes and shorter wave currents should be avoided as they produce unnecessary penetration of heat and uncontrolled tissue destruction. Clinically, in gingivoplasty, electrosurgical incisions are no different t,han those made by the scalpel. This is particularly true when superficial coagulated tissue is mechanically removed and a blood Gross coagulated tissue, if not extirpated by curettage, is clot encouraged. likely to be followed by toxic absorption, with symptoms of a second degree burn, Overcoagulation may be followed by active hyperemia. Secondary infection and a defensive reaction may manifest themselves with subsequent formation of inflammatory superfluous granulat,ion tissue.
ELECTROSURGICAL
GIKGIVOPLASTP
1555
The electrosurgical techniques developed for pocket elimination are: (1) gingivotomy, (2) gingivectomy, (3) electrocoagulation, and (4) fulguration. Individual Resection (Gingivotomy) .-This technique has been fully described.g It is a conservative approach to the resection of detached or hyperplastic gingival tissue, constituting the soft tissue side of localized pockets. Electrosection lends itself to extremely delicate dissections and to the molding of tissue. Electrosurgical effects thus produced cannot be simulated by the knife or any other means. The technique consists of three steps: (1) Festooning of the detached tissue by the elliptical loop electrode; (2) coning of interproximal tissue with the needle electrode; (3) planing of shelves by the round loop electrode. Electrosurgical Gingivectomy.-This technique has been fully described previously.1° It is a combination of surgery and electrosurgery and has the advantages of both. The fine cutting qualities of the electrode and, in addition, the hemostatic and sterilizing properties of high-frequency currents are utilized in this operation. This method lends itself to the management of periodontosis. An entire jaw may be treated at one sitting and the operation completed in about one-half hour. The technique consists of t,hree steps : 1. Resection of detached tissue by electrosurgical acusection. The incision follows the outline made by markings on the external surfaces of the gingivae, which represent the deepest portions of the pockets. The electrode used is a thin rigid wire, bent at a 45O angle. The current used is partially rectified and of a longer wave length, about 80 meters in wave length. The electrode cuts with ease and without pressure with a minimum amount of coagulation on either side of the cleavage. The incision may not necessarily be bloodless. It would be a mistake to use for cutting purposes a shorter wave length current or a heavier electrode in order to produce complete hemostasis. Such practice would invite inevitable postoperative sloughin g and possible localized bone necrosis. The operator should be satisfied with the ease of cutting and versatility that the electrode offers. The cutting effect simulates the steel scalpel and yet it is reasonably bloodless. Furthermore, the incision is made down to and at or near the periosteum, a further precaution against thermal penetration into osseous tissue. The completed incision is clearly outlined, and to the naked eye coagulated tissue is hardly visible. 2. With a sharp knife this outline is retraced, cutting through the periosteum to bone. No further hemorrhage is induced as the capillaries in the periosteum are previously sealed. There seems to be no need for the use of an aspirator for this procedure, in marked contrast to gingivectomy performed by the steel knife. The strip of detached tissue is now lifted with a blunt instrument. 3. Extirpation of partially electrocoagulated inflammatory granulation tissue is performed with the aid of specially designed curets, scalers, and tissue files. Hemorrhage may be arrested by spottin, 0‘ with a blunt electrode and, more effectively, bay using a shorter wave current of about 60 meters’ wave length. It has been found by experience t,hat healing is prompt and the wound
1556
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stays clean if all the debris and devitalized and excess granulation tissue are thoroughly cleaned and a normal blood encouraged during the initial operation. Electrocoagulation.-Recently it has been advocated that in using the hydrocolloid technique, soft tissue around the gingival margins of the inlay preparation be destroyed by electrocoagulation, so that a wet slough is produced. A monoterminal, bipolar electrode in the form of a heavy blunt blade is used ; however, the effect produced is precisely the same as if the biterminal, bipolar electrode were used. Such pra,ctice may induce an uncontrolled diathermic penetration and result in postoperative discomfort and deformity. The application of electrocoagulation should be confined only to spot destruction of granulation tissue and to the sterilization of the accumulated blood during gingivectomy, and postoperatively for the reduction of superfluous granulation tissue. Fulguration.-The fulgurating or desiccating current is safer to use. This method offers precision control with localized surface destruction. A thin wire monoterminal, monopolar electrode is used. Body resistance is raised by deleting the dispersive pad. Excess tissue may be dehydrated by showering electronic sparks on the surface of the tissue. Incisions made with this current, at the gingival margin for the exposure of buccal gingival caries, are bloodless, and the cut surfaces are sealed with a dry slough. Fulguration and the gingivotomy technique as described are the methods of choice in place of electrocoagulation, whenever the interproximal tooth surface is to be exposed for cavity preparation. The Pack The application of a protective surgical cement pack is just as important as the operation itself. In all electrosurgical interventions and whenever possible it should be used routinely. A suitable slow-setting pack composed of zinc oxide, rosin, eugenol, benzaldehyde, and olive oil has been described previously. When mixed thick and applied to the wound it will set in twenty minutes and will protect the blood clot against irritation and infection. It should he replaced and maintained for at least ten days to two weeks. Whenever the pack is removed, the underlying tissue, while in the process of healing, should be clean and devoid of odor or mass sloughing. A reasonably clean mouth before operative procedures are undertaken assures less operative hemorrhage and better healing. It has been observed that nature’s efforts at healing should not be disturbed for a period of three weeks. Bernier and KaplanI found that regenerated tissue is completely epithelized during this period and histologically shows no difference from normal tissue at the end of the three-week period. Surgical healing, however, does not constitute completed healing and regeneration. The process of healing continues and is abated by routine prophylactic treatment, essential dental treatment, and exercise of the new tissue until a firm and healthy layer is regenerated. Final healing may take several months, though immediately after the protective pack is discontinued normal physiologic function may proceed with comfort to the patient.
ELECTROSURGICAL
GINGIVOPLASTY
1557
Summary Surgical and/or electrosurgical gingivoplasty is the direct approach to pocket elimination. The use of high-frequency currents in dentistry is now The delicately controlled current of developed to a safe and practical extent. the electronic generator will function with efficiency and precision and produce the desired effects. The cutting, coagulating, desiccating, and sterilizing effects It must bc fully realized that electronic are an adjunct to surgical technique. An unenergy is a potent means in our hands and must be used intelligently. derstanding of the behavior of electronic modalities on oral tissues and sufficient training in their clinical application have opened a wide scope of usefulness in dentistry, not only in pocket eliminat,ion but, also in various other phases of dental practice.
References 1. Webb, 2. 3.
4. 5. 6. 7. 8. 9.
10. 11.
G. Farrel: Electrosurgical Treatment of Pyorrhea: Preliminary Report of New Method, Australian J. Dent. 41: 375, 1937. Miiller, R.: Cited in Immencamp, A.: Electrosurgery in Dentistry, New York, 1938, American Cystoscope Makers! Inc. Ogus, William I.: Electrosurgery In Dentistry, D. Digest 48: 411,1942. Mouradian, A. J., Plummer, William, and Rawls, Paul C.: Electrosurgery (Kelly and Ward], Philadelphia, 1932, W. B. Saunders Company, pp. 10-25, chap. 2. Dentistry in Wartime Germany. Reports nos. 96, 357, 539, 919, and 947, Office of the Publication Board, Dept. of Commerce, Washington, D. C., 5. Am. Dent. A. 33: 409, 1946. Kaplan, Harry, and Mann, James 13.: How Is Pyorrhea Cured? A Comparative Study of Several Methods for the Treatment of Pyorrhea Alveolaris, J. Am. Dent. A. 29: 1741. 1942. Schluger, Sa
GINGIVOPLASTY
D.D.S.,” PHILADELPHIA,
PA.
Introduction fifteen years ago, Webb1 brought to the attention of the dental proSOME fession the use of electrocoagulation in the treatment of periodontal disease. His technique employed the bipolar, biterminal electrode, activated by a sparkgap type generator. The passage of high frequency current between the two poles of the active electrode produced internal heat, with the effect of instanElectrocoagulation was expounded and taneous coagulation of tissue protein. gained popularity, due to its simplicity and effectiveness. Clinical experience, however, soon revealed that this method had certain limitations. The deep penetration of heat could not be controlled and would occasionally result in destruction of healthy tissue as well. The substitution of the spark-gap current by the electronic current of the vacuum-tube generator somewhat improved the control factor, but, inasmuch as electrocoagulation was not sufficiently substantiated by experimentation and the test of time, it could not overcome the adverse publicity it had built up for itself, and indirectly for electrosurgery. While electrocoagulation was in the limelight, little attention had been given to the early investigators in the field who had associated themselves with the development of electrosurgerg. The application of high-frequency currents for cutting, coagulating, or desiccating has been done as far back as 1909 both in Europe and the United States. Most of these methods having originated in Germany were subsequently taken up and developed in various surgical fields by our medical pioneers: Wyeth, Clark, Kelly, and others. In dentistry Miiller” employed the wire loop electrode and reported its use in 1924. One of our early investigators in this field, Ogus, collaborating with Kelly, was experimenting with the cutting currents during this developmental stage. Ogus3 was introduced to electrosurgery in 1925 by Elmer Brown Clark of Trenton, New Jersey, who had seen the work of Clark in Philadelphia. sent Ogus to meet Kelly and Ward at Johns Hopkins University in Baltimore, Maryland. These eminent surgeons were using the high-frequency current in general surgery, utilizing it for deep coagulation and destruction of precancerIn 1940, Ogus was invited ous and cancerous masses, where this was indicated. to give a paper before the staff of Johns Hopkins University under the sponsorship of Professor Kelly and Professor Ward. Dr. Kelly was impressed by the Read before the Pennsylvania State Dental Society and the Odontological Society Western Pennsylvania, Pittsburgh. Pa.. June 2. 1949. *Associate in Stomatology, Graduate School of Medicke, University of Pennsylvania. 1549
of
1550
LEVON
$1. SAGHIRIAN
presentation and, in putting the stamp of approval on electrosurgcry for dentistry, expressed himself, “. . . I think it to be one of the most remarkable and practical discoveries in surgery? since I have come into the field back in the eighties of the last century.” This author’s interest was aroused independently in 1933 at the Graduate Hospital in Philadelphia, while observing the early use of high-frequency currents in the fields of dermatology, gynecology, proctology, and thoracology. Collaborating wit,h W. J. Johnson, then head of the Department of Physical Medicine, a number of clinical cases were treated with primitive spark-gap t,ype high frequency equipment available at that time. The brief popularity of elect,rocoagulation during this period and its apparent limitations react,ivated our interest in oral electrosurgery, more so when newer-designed electronic equipment was made available to us for experimentation. Early clinical research was directed to the resection of excess tissue, growths, changing of tissue attachments, and the incision and draina.ge of abscesses. It was in the field of periodontal surgery that, with the abundance of clinical material available, electrosurgery found wide use in pocket elimination and the molding of tissue. With the use of this new technique, it was apparent t,hat the close proximit? of the oral mucosa to alveolar bone and the dental structures, as well as other biologic factors peculiar to the mouth, necessitated the development of (a) the type of equipment best suited for our needs and (1)) a technique which would make electrosurgery reasonably safe and practical.
Electronics The science of electronics covers the emission of electrons t.hrough free space (vacuum) or through appropriate gases, as well as control of electrons under these conditions. It does not explain the behavior of electrons when flowing in solid conductors such as copper wire or tungsten electrodes. Radio and electronics, as a result of research and experimentation, from their inception have been closely relat,ed. Electronics is an offspring of radio. The Fleming valve (1903) and the De Forest hudion (1906) were t.he first “vacuum tubes” and as such mark the entrance of the electronic era. The Triode oscillator and t,he Triode amplifier, which came about 1912, were developments in tube circuit. and serve as oscillation generators and amplifiers of weak radio signals. The present, wide application of tubes and the science of electronics in radar, television, facsimile electronic emission, and high frequent> heating in industry is evidence of the success of this development. X distinction must be made between the types of machines used in surgery. They are : (I) the spark-gap type ; (2) the vacuum-tube type : and (3) the combinat,ion spark-gap and vacuum-tube type. The spud-gap type apparatus produces electrical waves of high frequency. The condenser, spark-gap, and resonator form the high-frequency oscillating The oscillations of the spark-gap machina are damped; they are not circuit. continuous but occur in separate oscillating periods, each consisting of a series
ELECTROSURGICAL
GINGIVOPLASTY
3551
The frequency of oscillations varies of rapidly decreasing oscillation trains. from 500,000 to 2,000,OOOper second. The spark-gap apparatus produces principally a current suitable for fine desiccation, fulguration, and heavy coagulation. The zmuwna-tube apparatus produces high-frequency oscillations of someMuch higher what different character than that of the spark-gap machine. The oscillations are damped ; they are continuous frequencies are produced. The frequencies vary between 10,000,000 and and have a uniform amplitude. 100,000,000 per second. The vacuum-tube apparatus is primarilv suited for fine cutting and coagulating. This type of apparatus may be modified by rectification and variance in tank coil and condensers to produce varying wave lengths and patterns, so that suitable fulgurating effects as well may be produced. Similarly, the spark-gap apparatus may be modified to produce satisfactory cutting effects. Combination ,~pa~li-g~~ and tube-t!ype machines are also available where a blended current is desired. The surgeon has a selection in the use of the sparkgap current, the vacuum-tube current, or a combination of the two in any proportion desired. These machines, being bulky, are more suitable for use in the hospital operating room. The dentist will find tire vacuum-tube apparatus compact and versatile for all oral electrosurgical procedures required in office use. F’undamental research in the science of electronics in various scientific and industrial fields has contributed to a better understanding of the behavior of high-frequency currents. Mouradian, Hummer, and Rawls’ applied this knowledge to engineering perfection in medical-surgical equipment. In our experiments we were further aided by engineering consultants in making the necessary modifications and in designing equipment of a standard of efficient>- which would serve our purpose. We have now at our disposal units with satisfactory range of wave lengths, patterns, and power which control the performance of delical-e electrodes of our own design. This knowledge has been coordinated with developmental research carried on in the clinic and in private practice for over fifteen years in order to arrive at a practical technique.
Definition of Electrosurgery Electrosurgery is the surgical use of electricity in one form or another. In the strictest sense of the term it covers all forms of endothermic applications on human tissue, as well as t,he use of the electrocautery, electrolysis, and other electrochemical means for the destruction of tissue. General modern usage, however, has restricted the term electrosurgery to the surgical applicat.ion of high-frequency electric currents. The surgeon must understancl current characteristics produced by various frequencies and wave patterns and must learn through experimentation how to control these currents before attempting to use electrosurgery. Electrosurgical methods are an adjunct to scalpel surgery. The principal effects produced are: (1) fi ne almost bloodless dissections by acusection; (2)
1552
LEvON
M , SBGHIRIAK
hemostasis and destruction of tissue by electrocoagulation ; (3) dehydration of surface lesions by fulguration or desiccation; (4) sterilization. These effects are interrelated, ant4 best results are produced by skillful combinations.
The Electrode The active electrode is sometimes called the cold cutting knife or the radio knife, because the electronic knife remains cold all through the operation and the heat generated in the tissues is always under the control of t,he operator. A coagulating or cutting current is produced, depending on the frequency, the wave pattern, the strength of the current, or the size and shape of the electrode. In contrast, the low-voltage electric current in the cautery functions only as a means of heating and maintaining the temperature of the instrument or electrode employed, much as a heated wire would. Searing or burning is produced by a red hot instrument ih contact with tissue.
Pocket Elimination Regardless of the method of choice, one thing is constant: periodontal disease cannot be cured or arrested unless the pathologic crevice is either closed or reduced to near zero. If we feel that reattachment of detached tissue is not feasible, then we must direct our attention to pocket elimination either by shrinkage or by resection. It is not the purpose of this report to discuss the relative merits of the two approaches to the same problem, pocket elimination. Both methods have their Undoubtedly, successful results are produced by either ardent advocates. means, In the final analysis, decision as to which one to use rests on the clinical judgment and experience of the operator. There is at present a well-established concept among periodontists that gingivoplasty is the direct approach to surgical, chemical, or electrosurgical pocket elimination. History records that surgery was attempted by the ancient Babylonians and Egyptians. Not only gum resections were practiced with sharp objects, but the hot poker also played its part for the destruction of diseased tissue. Surgical methods utilizing the knife are as old as the profession itself. They were described by Fauchard in 1746, Robiesek in 1862, and Riggs in 1867. Reports from Germany5 indicate that durin, 0 the last war period the dental profession in continental Europe followed the surgical trend and gingivectomy was practiced more extensively than in the United States. This perspective is is not being regarded now gaining headway in this country, and gingivoplasty only as the last resort, but an effective and practical means of pocket elimination in cases where a diagnosis would indicate prompt and certain eradication. In discussing pocket elimination by electrosurgery, it is the purpose of this report to deliberate not only on the advantages of this method but also on its possible harmful effects, through the use of inadequate equipment or faulty technique. Electrosurgery has many applications in dental practice. It lends itself particularly well to the treatment of chronic periodontal disease.
ELECTROSURGICAL
GINGIVOPLASTY
1553
Periodontosis We must bear in mind that periodontosis is a chronic degenerative disturbance and involves the destruction of the periodontal membrane and regressive is noninchanges in the supporting alveolar bone. The disease fundamentally flammatory in character, though it is seldom observed in an aseptic form. It occurs more often associated with periodontitis or hyperplasia. The etiology of this disease is often difficult to determine. It is assumed to be associated with, if not caused by, systemic dyscrasia. Periodontosis is not uncommon in the young, when it is related to a systemic dyscrasia, such as diabetes, endocrinopathic conditions, nutritional deficiencies, or to oral sepsis. However, in individuals past the age of 20 it is the most prevalent of human diseases including caries. More teeth are lost through this cause than any other. The sooner the disease is detected the sooner it can be arrested or cured. It is the duty of every dentist to educate the public in preventive dentistry. It is cowardly to ignore the treatment of periodontosis by simply labeling it incurable. Clinically, periodontosis characterizes itself with the existence of the pathologic pocket. The boundaries of this space are, on one side, the cementum of the tooth in whatever state of health it might be and, on the other side, the surface of the detached or excess tissue. The pathologic picture also involves the epithelial drift in advance of the pocket and bone resorption in the infiltrated area. In the presence of periodontitis the crevicular epithelium is ulcerated and the gingival corium inflammatory in character. The contents of this space may include debris, necrotic tissue, calculus, inflammatory granulation tissue, and an abundance of extravascular fluids and pus. The primary consideration in periodontosis is the extent of regressive changes that has taken place in the alveolar bone. The onset of periodontosis may be detected in advance, hefore vital tooth attachment is dangerously lost, by careful radiographic examinations, made periodically. Kaplan and Mann6 demonstrated conclusively that the elimination of the pocket will arrest the disease and make its cure possible, Healing is prompt following surgical and electrosurgical gingivoplasty. Soft tissue regenerates over the existing level of alveolar bone. Nature will smooth and round. alveolar bone as soon as the exciting symptoms are relieved and healing proceeds. Osteosis may heal completely if the process of regeneration by resorption and formation of bone proceeds undisturbed. Clinically, following pocket elimination the picture changes from the pathologic state to that of normal periodontal health which simulates a state of physiologic recession.
Osseous Resection It is not necessary, nor is it advisable, in practicing gingivoplasty to file or mutilate alveolar bone in any way, except in certain instances in which architectural requirements indicate it. These cases are fortunately in the minority RSpointed out by Schluger.? Elimination of periodontal disease by gingivoplasty should be attempted
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M.
SAGHIRIAN
only where the teeth involved are firmly supported in bone. Where osteolysis has regressed to such a great extent that isolated deep intraosseous pockets exist, an additional problem presents itself. Whether or not deep bone pockets may close by regeneration with gingivectomy alone is a moot quest,ion. In certain selected cases b,one resection and reshaping are needed. These cases should be studied in advance by careful radiographic and clinical examination. They require special consideration, and any one of the following procedures may be indicated : 1. Removal of the contents of the space including all traces of necrotic cementum on the root surface. If it is possible to protect the blood clot against infection and irritation either by a flap operation or pack, then organization of connective tissue and later bone regeneration may be expected. The influence and other factors should be of the endocrine glands, vitamin D, vascularity, considered. 2. Reshaping t,he bone to conform with architectural requirements so that tissue will heal with deflecting contours. 3. Extra&ion of the tooth if much vital bone support has been lost or would have to be sacrificed. The cosmetic effects and postoperative hypersensitivity of denuded root surfaces should be considered. We may be confronted at times with the choice of losing the tooth or accepting an inevitable recession.
Gingivoplasty The purpose of gingival surgery is t,o eliminate pockets, mold tissues, and aid nature in restoring the periodontium to a physiologic state. In order to attain this goal it is necessary to remove pathologic and excess tissue, to remove the soft tissue side of pockets, and to produce deflecting contours and interproximal sluiceways. Methods of gingivoplasty are classified into the surgical, chemical, and electronic groups.8 Each will give sat,isfactory results when surgical principles are followed.
Electrosurgical
Techniques
The cardinal rule in regula,ting the strength of current is that one should always use the lowest strength that cuts freely to the desired depth, and one should choose the size and shape of electrode according to electrical resistance of tissue under the electronic knife. All incisions should be made bolcll~, without hesitation, and following a predetermined pattern. The use of heavy electrodes and shorter wave currents should be avoided as they produce unnecessary penetration of heat and uncontrolled tissue destruction. Clinically, in gingivoplasty, electrosurgical incisions are no different t,han those made by the scalpel. This is particularly true when superficial coagulated tissue is mechanically removed and a blood Gross coagulated tissue, if not extirpated by curettage, is clot encouraged. likely to be followed by toxic absorption, with symptoms of a second degree burn, Overcoagulation may be followed by active hyperemia. Secondary infection and a defensive reaction may manifest themselves with subsequent formation of inflammatory superfluous granulat,ion tissue.
ELECTROSURGICAL
GIKGIVOPLASTP
1555
The electrosurgical techniques developed for pocket elimination are: (1) gingivotomy, (2) gingivectomy, (3) electrocoagulation, and (4) fulguration. Individual Resection (Gingivotomy) .-This technique has been fully described.g It is a conservative approach to the resection of detached or hyperplastic gingival tissue, constituting the soft tissue side of localized pockets. Electrosection lends itself to extremely delicate dissections and to the molding of tissue. Electrosurgical effects thus produced cannot be simulated by the knife or any other means. The technique consists of three steps: (1) Festooning of the detached tissue by the elliptical loop electrode; (2) coning of interproximal tissue with the needle electrode; (3) planing of shelves by the round loop electrode. Electrosurgical Gingivectomy.-This technique has been fully described previously.1° It is a combination of surgery and electrosurgery and has the advantages of both. The fine cutting qualities of the electrode and, in addition, the hemostatic and sterilizing properties of high-frequency currents are utilized in this operation. This method lends itself to the management of periodontosis. An entire jaw may be treated at one sitting and the operation completed in about one-half hour. The technique consists of t,hree steps : 1. Resection of detached tissue by electrosurgical acusection. The incision follows the outline made by markings on the external surfaces of the gingivae, which represent the deepest portions of the pockets. The electrode used is a thin rigid wire, bent at a 45O angle. The current used is partially rectified and of a longer wave length, about 80 meters in wave length. The electrode cuts with ease and without pressure with a minimum amount of coagulation on either side of the cleavage. The incision may not necessarily be bloodless. It would be a mistake to use for cutting purposes a shorter wave length current or a heavier electrode in order to produce complete hemostasis. Such practice would invite inevitable postoperative sloughin g and possible localized bone necrosis. The operator should be satisfied with the ease of cutting and versatility that the electrode offers. The cutting effect simulates the steel scalpel and yet it is reasonably bloodless. Furthermore, the incision is made down to and at or near the periosteum, a further precaution against thermal penetration into osseous tissue. The completed incision is clearly outlined, and to the naked eye coagulated tissue is hardly visible. 2. With a sharp knife this outline is retraced, cutting through the periosteum to bone. No further hemorrhage is induced as the capillaries in the periosteum are previously sealed. There seems to be no need for the use of an aspirator for this procedure, in marked contrast to gingivectomy performed by the steel knife. The strip of detached tissue is now lifted with a blunt instrument. 3. Extirpation of partially electrocoagulated inflammatory granulation tissue is performed with the aid of specially designed curets, scalers, and tissue files. Hemorrhage may be arrested by spottin, 0‘ with a blunt electrode and, more effectively, bay using a shorter wave current of about 60 meters’ wave length. It has been found by experience t,hat healing is prompt and the wound
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stays clean if all the debris and devitalized and excess granulation tissue are thoroughly cleaned and a normal blood encouraged during the initial operation. Electrocoagulation.-Recently it has been advocated that in using the hydrocolloid technique, soft tissue around the gingival margins of the inlay preparation be destroyed by electrocoagulation, so that a wet slough is produced. A monoterminal, bipolar electrode in the form of a heavy blunt blade is used ; however, the effect produced is precisely the same as if the biterminal, bipolar electrode were used. Such pra,ctice may induce an uncontrolled diathermic penetration and result in postoperative discomfort and deformity. The application of electrocoagulation should be confined only to spot destruction of granulation tissue and to the sterilization of the accumulated blood during gingivectomy, and postoperatively for the reduction of superfluous granulation tissue. Fulguration.-The fulgurating or desiccating current is safer to use. This method offers precision control with localized surface destruction. A thin wire monoterminal, monopolar electrode is used. Body resistance is raised by deleting the dispersive pad. Excess tissue may be dehydrated by showering electronic sparks on the surface of the tissue. Incisions made with this current, at the gingival margin for the exposure of buccal gingival caries, are bloodless, and the cut surfaces are sealed with a dry slough. Fulguration and the gingivotomy technique as described are the methods of choice in place of electrocoagulation, whenever the interproximal tooth surface is to be exposed for cavity preparation. The Pack The application of a protective surgical cement pack is just as important as the operation itself. In all electrosurgical interventions and whenever possible it should be used routinely. A suitable slow-setting pack composed of zinc oxide, rosin, eugenol, benzaldehyde, and olive oil has been described previously. When mixed thick and applied to the wound it will set in twenty minutes and will protect the blood clot against irritation and infection. It should he replaced and maintained for at least ten days to two weeks. Whenever the pack is removed, the underlying tissue, while in the process of healing, should be clean and devoid of odor or mass sloughing. A reasonably clean mouth before operative procedures are undertaken assures less operative hemorrhage and better healing. It has been observed that nature’s efforts at healing should not be disturbed for a period of three weeks. Bernier and KaplanI found that regenerated tissue is completely epithelized during this period and histologically shows no difference from normal tissue at the end of the three-week period. Surgical healing, however, does not constitute completed healing and regeneration. The process of healing continues and is abated by routine prophylactic treatment, essential dental treatment, and exercise of the new tissue until a firm and healthy layer is regenerated. Final healing may take several months, though immediately after the protective pack is discontinued normal physiologic function may proceed with comfort to the patient.
ELECTROSURGICAL
GINGIVOPLASTY
1557
Summary Surgical and/or electrosurgical gingivoplasty is the direct approach to pocket elimination. The use of high-frequency currents in dentistry is now The delicately controlled current of developed to a safe and practical extent. the electronic generator will function with efficiency and precision and produce the desired effects. The cutting, coagulating, desiccating, and sterilizing effects It must bc fully realized that electronic are an adjunct to surgical technique. An unenergy is a potent means in our hands and must be used intelligently. derstanding of the behavior of electronic modalities on oral tissues and sufficient training in their clinical application have opened a wide scope of usefulness in dentistry, not only in pocket eliminat,ion but, also in various other phases of dental practice.
References 1. Webb, 2. 3.
4. 5. 6. 7. 8. 9.
10. 11.
G. Farrel: Electrosurgical Treatment of Pyorrhea: Preliminary Report of New Method, Australian J. Dent. 41: 375, 1937. Miiller, R.: Cited in Immencamp, A.: Electrosurgery in Dentistry, New York, 1938, American Cystoscope Makers! Inc. Ogus, William I.: Electrosurgery In Dentistry, D. Digest 48: 411,1942. Mouradian, A. J., Plummer, William, and Rawls, Paul C.: Electrosurgery (Kelly and Ward], Philadelphia, 1932, W. B. Saunders Company, pp. 10-25, chap. 2. Dentistry in Wartime Germany. Reports nos. 96, 357, 539, 919, and 947, Office of the Publication Board, Dept. of Commerce, Washington, D. C., 5. Am. Dent. A. 33: 409, 1946. Kaplan, Harry, and Mann, James 13.: How Is Pyorrhea Cured? A Comparative Study of Several Methods for the Treatment of Pyorrhea Alveolaris, J. Am. Dent. A. 29: 1741. 1942. Schluger, Sa