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gingivectomy
1. Periodontal Surgery:
Access Therapy
Since most forms of periodontal disease are
plaque associated disorders,
it is obvious that surgical access therapy can only
be considered as adjunctive to cause -related
therapy.
Therefore, the various surgical methods
described below should be evaluated on the
basis of their potential to facilitate removal of
subgingival deposits and self-performed plaque
control and thereby enhance the long-term
preservation of the periodontium.
2. The decision concerning what type
of periodontal surgery should be
performed and how many sites
should be included is usually made
after the effect of initial cause-
related measures has been
evaluated.
The time lapse between termination
of the initial cause-related phase of
therapy and this evaluation may
vary from 1 to 6 months.
3. This routine has the following advantages:-
• The removal of calculus and bacterial plaque will eliminate or
markedly reduce the inflammatory cell infiltrate in the gingiva
(edema, hyperemia, flabby tissue consistency), thereby making
assessment of the "true" gingival contours and pocket depths
possible.
• The reduction of gingival inflammation makes the soft tissues
more fibrous and thus firmer, which facilitates surgical handling
of the soft tissues. The propensity for bleeding is reduced,
making inspection of the surgical field easier.
•A better basis for a proper assessment of the prognosis has been
established. The effectiveness of the patient's home care,
which is of decisive importance for the long-term prognosis, can
be properly evaluated.
Lack of effective self-performed care will often mean that the
patient should be excluded from surgical treatment.
4. Indications
_Gingival enlargement or overgrowth (caused by
medicaments or hormonally)
- Idiopathic fibrosis
_ Suprabony pockets in areas with limited
access
_ Minor corrective procedures
5. Contraindications
_Narrow or absent attached gingiva
–Infrabony pockets
_Thickening of marginal alveolar bone
Advantages
_Technically simple; good visual access
_Complete pocket elimination
6. Disadvantages
-Very limited indication
_Gross wound; postoperative pain
_Healing is by secondary intent (ca. 0.5 nun re-
epithelialization per day)
-Danger of exposing bone
_Sacrifice of attached gingiva
_Exposes cervical area of tooth (sensitivity,
esthetics caries)
_Phonetic and esthetic problems in anterior
areas
7. Principles of the operative procedure
_Continuous incision at 45° angle toward the
base of the pocket
_Sharp dissection of tissues in the interdental
areas
_Smoothing of the incision edge
-Scaling and root planing
_Contouring of the gingival surface (GP)
_Wound coverage (periodontal dressing;
tissue adhesive)
8. Gingivectomy procedures
The surgical approach as an alternative to subgingival
scaling for pocket therapy was already recognized in
the latter part of the nineteenth century, when
Robicsek (1884) pioneered the so-called gingivectomy
procedure.
Gingivectomy was later defined by Grant et al. ( 1979)
as being "the excision of the soft tissue wall of a
pathologic periodontal pocket".
The surgical procedure, which aimed at "pocket
elimination", was usually combined with recontouring
of the diseased gingiva to restore physiologic form.
10. Electrosurgery - Device and tips
Electrosurgery finds its primary function in the gingivoplasty procedure,
where it is useful for contouring soft tissue, for papillectomy, for smoothing
out abrupt tissue edges, and for exposing the margins of restorations.
Electrosurgery is not recommended for expansive gingivoplasty because of
the possibility of injury to the tooth root, periosteum, bone or the tooth pulp.
11. Technique
The gingivectomy procedure as it is employed today was
described in 1951 by Goldman.
• When the dentition in the area scheduled for surgery has been
properly anesthetized, the depths of the pathologic pockets are
identified with a conventional periodontal probe (Fig. 3a).
At the level of the bottom of the pocket, the gingiva is pierced with
the probe and a bleeding point is produced on the outer surface
of the soft tissue (Fig. 3b).
The pockets are probed and bleeding points produced at several
location points around each tooth in the area.
The series of bleeding points produced describes the depth of the
pockets in the area scheduled for treatment and is used as a
guideline for the incision.
12. Fig. 3. Gingivectomy. Pocket marking. (a) An ordinary
periodontal probe is used to identify the bottom of the
deepened pocket. (b) When the depth of the pocket has been
assessed, an equivalent distance is delineated on the outer
aspect of the gingiva.
The tip of the probe is then turned horizontally and used to
produce a bleeding point at the level of the bottom of the
probeable pocket.
14. •The primary incision (Fig. 4), which may be
made by a scalpel (blade No. 12B or 15; or a
Kirkland knife No. 15/16, should be planned to
give a thin and properly festooned margin of
the remaining gingiva.
Thus, in areas where the gingiva is bulky, the
incision must be placed at a level more apical
to the level of the bleeding points than in areas
with a thin gingiva, where a less accentuated
bevel is needed.
The beveled incision is directed towards the
base of the pocket or to a level slightly apical
to the apical extension of the junctional
epithelium.
.
15. • In areas where the interdental
pockets are deeper than the buccal or
lingual pockets, additional amounts of
buccal and/or lingual (palatal) gingiva
must be removed in order to establish
a "physiologic" contour of the gingival
margin.
• This is often accomplished by
initiating the incision at a more apical
level
16. Fig. 4. Gingivectomy. (a) The primary incision. (b) The incision is
terminated at a level apical to the "bottom" of the pocket and is
angulated to give the cut surface a distinct bevel
17. •Once the primary incision is completed on the
buccal and lingual aspects of the teeth, the
interproximal soft tissue is separated from the
interdental periodontium by a secondary
incision using an Orban knife (No. 1 or 2) or a
Waerhaug knife (No. 1 or 2; a saw-toothed
modification of the Orban knife; Fig. 25-5).
Fig. 6. Gingivectomy. The detached
gingiva is removed with a scaler
Fig. 5. Gingivectomy. The secondary incision
through the interdental area is performed with
the use of a Waerhaug knife.
18. • The incised tissues are carefully removed by
means of a curette or a scaler (Fig. 25-6).
Remaining tissue tabs are removed with a
curette or a pair of scissors.
Pieces of gauze packs often have to be
placed in the interdental areas to control
bleeding.
When the field of operation is properly
prepared, the exposed root surfaces are
carefully scaled and planed.
19. • Following meticulous debridement, the dentogingival
regions are probed again to detect any remaining
pockets (Fig. 7). The gingival contour is checked and,
if necessary, corrected by means of knives or rotating
diamond burs.
20. • To protect the incised area during the period
of healing, the wound surface must be
covered by a periodontal dressing (Fig. 8).
The dressing should be closely adapted to the
buccal and lingual wound surfaces as well as
to the interproximal spaces.
Care should be taken not to allow the dressing
to become too bulky, since this is not only
uncomfortable for the patient, but also
facilitates dislodgement of the dressing.
21. Fig. 7. Probing for residual
pockets. Gauze packs have
been placed in the interdental
spaces to control bleeding.
Fig. 8. The periodontal dressing
has been applied and properly
secured
22. • The dressing should remain in position for 10-
14days. After removal of the dressing, the teeth
must be cleaned and polished.
The root surfaces are carefully checked and
remaining calculus removed with a curette.
Excessive granulation tissue is eliminated with
a curette.
The patient is instructed to properly clean the
operated segments of the dentition, which now
have a different morphology as compared to
the preoperative situation.
