GINGIVECTOMY

4545

HISTORICAL PERSPECTIVE

History of gingivectomy can be dated back to 1742, whenFauchard describe the procedure to remove excessivetissue. Robicsek in 1884, later on described the so calledgingivectomy procedure as straight incision techniquein which the tissues were excised and the granulationtissue eliminated. Pickerills book Stomatology inGeneral Practice, published in 1912, described theprocedure and very reasonably named the operationgingivectomy. Zentler in 1918 gave scalloped incisiontechnique for gingivectomy. Gingivectomy is thought tobe introduced as an official periodontal therapy whenthe idea of periodontal etiology shifts from bone to softtissue. This is mainly due to Kronfeld in 1935, whoemphasized that periodontal disease is not the diseaseof the bone. Gingivectomy was later defined by Grant etal in 1979 as being the excision of the soft tissue wall of apathologic periodontal pocket.

DEFINITION

According to the World Workshop in Periodontics (1989),gingivectomy is defined as an excision of the soft tissuewall of the periodontal pocket.

OBJECTIVES

i. Pocket elimination by gingival resection.ii. Development of physiologic tissue form for disease

prevention.

INDICATIONS

i. Elimination of suprabony pockets.ii. Elimination of gingival enlargement.

iii. Elimination of suprabony periodontal abscess.iv. To expose additional clinical crown to gain added

retention for restorative purposes and to provideaccess to subgingival caries.

v. The presence of furcation involvement (withoutassociated bone defects) where there is a wide zoneof attached gingiva.

vi. Pericoronal flap.

CONTRAINDICATIONS

i. The need for bone surgery or examination of the boneshape and morphology.

ii. Situations in which the bottom of the pocket is apicalto the mucogingival junction, gingivectomy will

1. Historical Perspective2. Definition3. Objectives4. Indications5. Contraindications6. Limiting Circumstances7. Drawbacks

Gingivectomy

Shalu Bathla

8. Gingivoplasty9. Types of Gingivectomy Procedure

Surgical Gingivectomy Laser Gingivectomy Gingivectomy by Electrosurgery Gingivectomy by Chemosurgery

10. Healing After Gingivectomy

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348 SECTION 6: SECTION 6: SECTION 6: SECTION 6: SECTION 6: Treatment: A. Non-surgical Therapy and B. Surgical Therapy

excise most of the gingiva and leave an inadequatezone of gingiva.

iii. Esthetic considerations, particularly in anteriormaxilla.

iv. If the patient complains of tooth senstivity beforesurgery. Although it is relative contraindication, asthe cause of any complaint should be treated beforethe surgery and if the sensitivity cannot becontrolled, surgery should be contraindicated.

LIMITING CIRCUMSTANCES

1. Palatal aspects of maxillary posterior teeth: When thepalatal vault is shallow and the depth of periodontalinvolvement is near or enters the vault area,gingivectomy on the palatal aspect of maxillaryposterior teeth may result in elimination of most ifnot all of the palatal gingiva, placing the gingivalmargin at or near a level of coincident with that ofthe roof of the mouth.

2. Mandibular retromolar lesions: When an incision ismade on movable and delicate mucosa, this tissueoften cuts poorly, bleeds profusely and may bedifficult to resect and shape. The use of the distalwedge procedure, often simplifies the managementof retromolar tissue.

3. Maxillary tuberosity areas: When soft tissue is so great,relative to the depth of periodontal involvement onthe distal aspect of the last molar, that its levelresection would bring about surgical entry into themucosa of the hamular notch. It may be moreappropriate to perform a distal wedge procedure toeliminate diseased tissue immediately adjacent to thedistal portion of the molar.

4. Cases of emotional stress: With age, diminish patientcooperation and motivation, retarded healing, etc.have a direct bearing upon the desirability of thesurgical therapy. Such patient is a poor surgical riskand requires therapeutic modification.

DRAWBACKS

1. Tissue wound heals by secondary intention.2. Alveolar bone defects are not revealed and therefore

cannot be treated adequately.3. Gingivectomy is a radical procedure in which zone

of attached gingiva is compromised/may beeliminated. Thus, attached gingiva is wasted.

4. Clinical crown are lengthened considerably and needto be explained to the patient before surgery.

5. It may lead to dentin hypersensitivity due to rootexposure.

GINGIVOPLASTY

Gingivoplasty first described by Goldman in 1950 as aplastic procedure of which the gingival tissue wasremoved. Sugarman in 1951 describe electrosurgicalgingivoplasty in his case report. Gingivoplasty can bedefined as recontouring of gingiva that has lost itsphysiologic form. Gingivoplasty was introduced tofacilitate dealing with abnormal form of gingiva and wasessentially a surgical procedure designed to reshapegingiva without necessarily reducing sulcular depth.

The purpose of gingivoplasty is different fromgingivectomy, as gingivoplasty is just reshaping ofgingiva to create physiologic gingival contours, with thesole purpose of recontouring the gingiva in the absenceof pockets, while the objective of gingivectomy is toeliminate pocket.Indications of gingivoplasty:

i. Need for correction of the grossly thickened gingivalmargin.

ii. Gingival clefts and craters caused by necrotizingulcerative gingivitis that interfere with normal foodexcursion, collect plaque and food debris.

iii. Sharply varying levels of gingival margin in adjacentareas.

iv. Saucer shaped deformities, buccolingual in theinterproximal regions.

Instruments: Gingivoplasty may be done with aperiodontal knife, scalpel, rotary coarse diamond stonesor electrode.

Steps in the gingivoplasty procedure are similar andresembles those performed in festooning artificialdentures namely:

i. Tapering the gingival margin.ii. Creating a scalloped marginal outline.

iii. Thinning the attached gingiva.iv. Creating vertical interdental grooves and shaping

the interdental papillae to provide embrasures forthe passage of food.

Scrapping: Use a scalpel as a hoe and pass the instrumenttightly but firmly over a firm, tough tissue surface whichresults in shaving of the surface. The use of rotary abrasivesconsists essentially of abrading tissue until it has assumedthe desired form. The rules governing the application ofthe rotary abrasive to soft tissue are exactly those that applyto hard tissue. A steam of water on the instrument

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349CHAPTER 45: CHAPTER 45: CHAPTER 45: CHAPTER 45: CHAPTER 45: Gingivectomy

expediates the procedure immeasurably just as it does onbone, enamel or dentin. Accelerated speed ensures asmooth, rapid operation while the stream of water providestemperature control and prevents clogging of instruments.

TYPES OF GINGIVECTOMY PROCEDURE

Surgical Gingivectomy

Surgical Instruments

Pocket markers: Goldman-fox, Crane Kaplan(Fig. 45.1A)

Broad-bladed, round scalpels: Goldman-fox no. 7,Kirkland knife (Fig. 45.1B)

Interproximal knife: Goldman-fox no. 8, 9 and 10,Orbans knife (Fig. 45.1C)

Surgical handle: Bard Parker no.3 or angulatedhandle (Blakes handle) with blade no 11,12,15

Curettes Tissue nipper (Fig. 45.2), scissors.

Procedure

Mark bleeding points: After LA is given in the selectedsite, mark bleeding points with the help of pocketmarker systematically, beginning on the distal surfaceof the tooth, then on the facial and mesial surface.The procedure is repeated on the lingual/palatalsurface. Beak of pocket marker must be parallel toroot surface. Pinpoint perforations individuate pocketdepth which is used as a guideline for the incision.

Incisions: Discontinuous/continuous incision is givenapical to the bottom of the bleeding point beginningat the most terminal tooth (Fig. 45.3). External bevelincision is given at an angle of 45 apical to the baseof the pocket with the help of Kirkland knife or bladeno.11 or 15 with BP handle no.3 or angulated Blakeshandle. The blade must pass fully through the tissueto the tooth in coronal direction (Figs 45.4 and 45.5).The incision should be as close as possible to the bonewithout exposing it so as to remove the soft tissuecoronal to the bone. The main principle here is toeliminate pocket all the way to the base withoutexposing the bone. Once the primary incision iscompleted on the buccal and lingual aspect, Orbansknife or Waerhaug knife is placed at angle of 45 tofree the tissue interproximally.

Tissue removed: The incised tissues are carefully removedwith the help of curette or scaler. The remaining tissuetabs are removed with scissors. The gingival marginsshould be thin and beveled and if necessary correctedby means of knives or rotating diamond burs.

Scaling and root planing: The calculus and necroticcementum on the tooth are removed with the help ofscalers and curettes.

Periodontal dressing: Bleeding is controlled and afterthat periodontal dressing is applied over the treatedsite primarily for patient comfort. Thereafter, patientis given postoperative instructions.

Laser Gingivectomy

The lasers most commonly used for gingivectomy arethe CO2 having wavelength of 10600 nm andNeodymium:yttrium-Aluminium-garnet (Nd:YAGtr)having wavelength of 1064 nm both in infrared range.

Fig. 45.1: A. Pocket marker. B. Kirkland knife C. Orbans knife.

Fig. 45.2: Tissue nipper

A B C

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Advantages

i. Laser offers an almost completely dry, bloodlesssurgery.

ii. Because of dried field, surgical time may be reduced.iii. There is instant sterilization of the area, decreasing

the chances of bacteremia.iv. This is noncontact surgery, thus no mechanical

trauma to the surgical site.v. There is prompt healing with minimal postoperative

swelling and scarring.vi. Postoperative pain appears to be greatly reduced.

Disadvantages

i. There is loss of tactile feedback in using theinstrument.

ii. It is imperative that all operating room personnelwear safety glasses for protection of their eyes.

iii. There is the necessity for hospitalization.iv. High cost of the equipment.

Gingivectomy by Electrosurgery

Instruments: Needle electrode (thickness varying from0.0075 inch to 0.015 inch), small ovoid loop/diamondshaped electrodes.

Procedure: The site must not be too dry otherwiseexcessive sparking will result. Conversely, if excessivemoisture is present, considerable surface coagulation willoccur instantly. For the best results, the site should be veryslightly moist. The removal of gingival enlargements andgingivoplasty is performed with the needle electrode,supplemented by the small ovoid loop/ diamond shapedelectrodes for festooning. A blended cutting andcoagulating (fully rectified) current is used. In allreshaping procedures, electrode is activated and movedin a concise shaving motion. Electrode should be kept inconstant motion in order to prevent a build-up of heatwith appropriate current setting and the patient shouldbe properly grounded. Clean all debris from electrodeswith gauze sponges after each movement through softtissue. The sponge may be dry or moistened with absoluteisopropyl alcohol.

Advantages

i. It provide clear operating area with little/no leeding.ii. Lack of pressure to incise tissue, thus allowing a more

precise incision than is obtained by a scalpel.iii. Minor tissue loss after healing.

Figs 45.5A and B : (A) Incorrect incisions: 1. Shallow incision (Fail toremove pocket), 2. No bevel incision (Result in bone exposure); (B)Correct incision

Figs 45.3: Incisions: (A) Discontinuous incision;(B) Continuous incision

Fig. 45.4: Mark the depth of pocket with pocket marker and giveexternal bevel incision apical to the bleeding point making 45 angleto the long axis of tooth

B

A

A B

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351CHAPTER 45: CHAPTER 45: CHAPTER 45: CHAPTER 45: CHAPTER 45: Gingivectomy

iv. Self-sterilization of the tip of the active electrode.v. Scar-free healing by primary intention, when used

properly.vi. Greater ease for the patient as well as for the operator.

Disadvantages

It causes an unpleasant odor. If the electrosurgery point touches the bone,

irreparable damage can occur. When electrode touches the root, areas of cementum

burns are produced.

Contraindication

One major contraindication to electro-surgery is a cardiacpacemaker. Since an electrosurgical unit generatesradiofrequency energy, it should never be used within15 feet of an individual with a cardiac pacemaker.

Gingivectomy by Chemosurgery

Five percent paraformaldehyde or potassium hydroxidewere the chemicals used to perform gingivectomy whichis no longer in use because of the followingdisadvantages associated with it: The depth of chemical action cannot be controlled. Gingival remodeling cannot be accomplished

effectively. Epithelialization and reformation of the junctional

epithelium, re-establishment of the alveolar crest fibersystem are slower in chemically treated gingivalwounds than in those produced by scalpel.

HEALING AFTER GINGIVECTOMY

Healing after gingivectomy is by secondary intention.Bernier J and Kaplan H reported the following timesequence for healing following gingivectomy in humans.The initial response after gingivectomy is the formationof a protective surface clot; the underlying tissue becomesacutely inflamed with some necrosis.

The outer epithelium heals by approximately 14days but sulcular epithelium requires 3 to 5 weeks toheal. Twelve hours after gingivectomy there is slightreduction in cementoblasts and some loss of continuityof the osteoblastic layer on the outer aspect of alveolarcrest. New bone formation occurs at the alveolar crestas early as the 4th day after gingivectomy and newcementoid appears after about 10 to 15 days.

Thus, total gingivectomy healing takes place in about4 to 5 weeks and remodeling of the alveolar bone crest

has been shown to occur during this phase. Gingivoplastywound often heal faster than gingivectomy wound.

2nd day Clot formation

4th day Clot replaced by granulation tissue Epithelium without rete pegs extends over part

of the surface Dense inflammatory infiltration

6th day Wound is covered by stratified squamous

epithelium Collagen formation starts in the connective tissue

16th day Epithelium with rete pegs appear

Dense collagenous connective tissue appears

21st day Epithelial rete pegs well developed, withthickening of stratum corneum

Increased Collagen formation in the connectivetissue

Gingiva clinically appear normal

The tissue changes that occur in post gingivectomyhealing are the same in all individuals, but the timerequired for complete healing varies, depending uponthe local and systemic factors influencing wound healing(interference from local irritation, infection and age).

Gingivectomy may be performed be means of scalpels, lasers,electrode or chemicals.In gingivectomy, external bevel incision is given at 45 to thetooth surface in apicocoronal direction.Gingivectomy wound heals by secondary intention.

POINTS TO PONDER

9 Failure to produce beveled incision leaves a broadplateau which takes more time than ordinarilyrequired to develop the physiologic contour ofgingiva, thus the incision should be beveled atapproximately 45 to the tooth surface.

9 The granulomatous tissue is removed first and thenthorough scaling is attempted on the tooth, so thathemorrhage from the granulomatous tissue shouldnot obscure the scaling during surgical procedure.

BIBLIOGRAPHY

1. Carranza FM, The gingivectomy technique. In, Newman, Takei,Carranza. Clinical Periodontology, 9th ed Saunders 2003;749-53.

2. Electrosurgical Management of soft tissues and restorativedentistry. Dent Clin North Am 1980;24(2):247-69.

3. Genco RJ, Rosenberg ES, Evian C. Periodontal surgery. In, GencoRJ, Goldman HM, Cohen DW. Contemporary Periodontics. CVMosby 1999;554-84.

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4. Gingivectomy and Gingivoplasty. In, Grant DA, Stern IB,Listgarten MA. Periodontics 6th ed CV Mosby Company1988;761-85.

5. Gingivectomy, wound healing. In, Ramfjord SP and Ash MM.Periodontology and Periodontics. Modern Theory and Practice.1st ed AITBS Publisher and Distributor India 1996; 275-84.

6. Pick R, Pecaro B, Silberman C. The Laser Gingivectomy, the useof the CO2 laser for the removal of Phenytoin hyperplasia. JPeriodontol 1985;56(8):492-6.

7. Surgical Periodontal treatment. In, Eley BM, Manson JD.Periodontics, 5th ed Wright 2004;262-75.

8. Tibbetts LS, Ammons WF. Resective Periodontal Surgery. In,Rose LF, Mealey BL, Genco RJ, Cohen DW. Periodontics,Medicine, Surgery and Implants. Elsevier Mosby 2004;502-52.

9. Wang HL, Greenwell H. Surgical periodontal therapy.Periodontol 2000 2001;25:89-99.

10. Wennstrom JL, Heijl L Lindhe J. Periodontal Surgery: AccessTherapy. In, Lindhe J, Karring T, Lang NP. ClinicalPeriodontology and Implant dentistry, 4th ed BlackwellMunksgaard 2003;519-60.

MCQs

1. Which of the following about conventionalgingivectomy is false?A. Eliminate false pocketsB. Heal by secondary intentionC. Leads to decrease in the width of attached gingivaD. Provides accessibility to alveolar bone

2. Gingivoplasty is more likely to be useful in:A. NUGB. Juvenile periodontitisC. Desquamative gingivitisD. All of the above

3. Indication of gingivectomy is:A. Pocket depth below mucogingival junctionB. Infrabony pocketsC. 5 mm periodontal pocketD. A fibrotic area of the free gingiva that covers part

of the occlusal surface of tooth4. External bevel incision is beveled at approximately

_______ to the tooth surface.A. 15B. 30C. 45D. 90

5. Gingivectomy wound basically heals by:A. Secondary intentionB. Primary intentionC. Tertiary intentionD. None of the above

Answers

1. D 2. A 3. D 4. C 5. A

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GINGIVECTOMY