GINGIVECTOMY PROCEDURES

The surgical approach as an alternative to subgingival scaling for pocket

therapy was already recognized in the latter part of the 19th 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 recountering of the diseased

gingiva to restore physiological form.

Robicsek (1884) and, later, Zentler (1918) described the gingivectomy

procedure in the following way:

The line to which the gum is to be resected is determined first. Following a

straight (Robicsek; Fig. 16-10) or scalloped (Zentler; Fig. 16-11) incision, first on

the labia] and then on the Ungual surface of each tooth, the diseased tissue should

be loosened and lifted out by means of a hook-shaped instrument. After

elimination of the soft tissue, the exposed alveolar bone should be scraped. The

area should then be covered with some kind of antibacterial gauze or be painted

with disinfecting solutions. The result obtained should include eradication of the

deepened periodontal pocket and a local condition which could be kept clean

more easily.

Technique

The gingivecromy procedure as it is employed today was described 1951

by Goldman. When the dentition in the area scheduled for surgery has been

properly anesthesized, the. depths of the pathological pockets are identified either

with a pocket marking forceps (e.g. ad modum Crane-Kaplan: Fig. 16- 12a) or by

means of a conventional periodontal probe (Figs. 16-12b, c). At the level of the

bottom of the pocket, the gingiva is pierced with the blade of the forceps (probe)

and a bleeding point is produced on the outer surface of the soft tissue. 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 (he area scheduled for treatment and is used as a guideline for

the incision.

The primary incision (Fig. 16-13). which may be made by a scalpel (blade

No. 12B or 15; Bard-Parker ) in either a Bard-Parker handle or a Blake's handle,

or a Kirkland knife No. 15 or 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. 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.

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.

16-14).

The incised tissues are carefully removed by means of a curette or a scaler

(Fig. 16-15). 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.

Following meticulous debridement the dento-gingival regions are probed

again to detect any remaining pockets (Fig. 16-16). The gingival contour is

checked and. if necessary, corrected by means of knives or rotating diamond burs.

To protect the incised area during the period of healing, the wound surface

must be covered by a periodontal dressing (Fig. 16-17). 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

the dislodgement of the dressing. The dressing should remain in position for 10 to

14 days.

After removal of the dressing, the teeth must be cleaned and polished. The

root surfaces arc 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 niorphology as compared to the preoperative situation t Fig. 16-

18).

Healing and dimensional changes following gingivectomy

Within a few days following excision of the. inflamed gingival soft tissues

coronal to the base of the periodontal pocket, epithelial cells start to migrate over

the wound surface. The epithe-lialization of the gingivectomy wound is usually

complete within 7 to 14 days following surgery (Engler et al. 1966, Stahl et al.

1968). During the following weeks a new dento-gingival unit is formed (Fig. 16-

19). The fibroblasts in the supraalveolar tissue adjacent the tooth surface

proliferate (Waerhaug 1955) and new connective tissue is laid down. If this

regeneration occurs in the vicinity of a plaque-freetooth surface, a free gingival

unit will form which has all the characteristics of a normal free gingiva (Hamp et

al. 1975). This regeneration occurs in a coronal direction and appears clinically as

a gain in marginal height (Fig. 16-19c). The height of the newly formed free gin-

gival unit may vary not only between different parts of the dentition but also from

one tooth surface to another.

The reestablishment of a new, free gingival unit by coronal regrowth of

tissue from the line of the "gingivectomy" incision implies that sites with so-

called "zero pockets" only occasionally occur following gingivectomy. Complete

healing of the gingivectomy wound takes 4 to 5 weeks, although the surface of the

gingiva may appear by clinical inspection to be healed already after approximately

14 days (Ramfjord et al. 1966). Minor remodelling of the alveolar bone crest may

also occur during the healing phase.

GINGIVECTOMY

1. Procedure Description

A. The gingivectomy is a surgical procedure designed to excise or to remove

gingival tissue and was used for many years in periodontics as a primary

treatment modality.

B. Figure 21-7 shows a series of drawings that illustrate the incisions

involved in performing a gingivectomy.

2. Indications for Gingivectomy

A. Before the development of modern periodontal flap techniques, the

gingivectomy was in widespread use in the treatment of periodontitis

patients.

B. In modern periodontal therapy, the gingivectomy is usually limited to

removing enlarged gingiva to improve esthetics or to allow for better

access for self-care in isolated sites, though it can be used to reshape more

extensive areas of enlarged gingiva as might be seen in gingival

overgrowth in response to certain medication use. Figure 21-8 shows the

gingivectomy used to reshape an area of enlarged gingiva.

C. As a surgical technique, gingivectomy has several disadvantages:

1. One disadvantage to gingivectomy is that it leaves a large open

connective tissue wound that results in a somewhat slower surface

healing than most other periodontal surgical procedures. This generally

results in the expectation of more discomfort for the patient during the

healing phase.

2. Another disadvantage of gingivectomy is the resulting longer

appearance of the tooth due to the excision of some of the gingiva.

Despite this disadvantage, the gingivectomy is still a useful surgical

procedure in selected sites.

3. Healing After a Gingivectomy

A. The final healing of the wound created by a gingivectomy is a normal

attachment of the soft tissues to the tooth root, but at a level that is more

apical in position than the original level.

B. Following a gingivectomy, the teeth in the surgical area will appear to be

longer since more of the root is exposed where the tissue was excised. Of

course, if this is the desired result of the procedure—because of enlarged

gingiva—then, this procedure can result in an acceptable outcome.

However, if more tooth structure being exposed is not desirable, another

surgical approach may be indicated.

4. Special Considerations for the Dental Hygienist

A. As already mentioned, the gingivectomy wound leaves a broad connective

tissue surface exposed that can be very uncomfortable for the patient

during the healing phase.

B. Postsurgical discomfort can be managed by placing a periodontal dressing

(bandage material) over the wound and by prescribing analgesics (pain

medications) for use following surgery.

C. At the time of the first postsurgical visit, the dental hygienist may need to

replace the periodontal dressing to enhance wound comfort until total

epithelialization of the wound has occurred.

D. Healing of the wound created by a gingivectomy procedure progresses in a

predictable manner. Research studies have shown that oral epithelium

grows across the exposed connective tissue at an approximate rate of 0.5

mm per day. Thus it is possible for the alert clinical team to predict

healing times; this of course is useful when counseling patients about what

to expect during the postsurgical phase.

GINGIVAL CURETTAGE

1. Procedure Description

A. Gingival curettage is an older type of periodontal surgical procedure that

involves an attempt to scrape away the lining of the periodontal pocket

usually using a periodontal curet, often a Gracey curet.

1. Gingival curettage normally is not a part of modern periodontal

therapy. The procedure is discussed here briefly because the dental

hygienists wdll encounter many patients who have undergone this

procedure in the past and a few dentists who still recommend some

variation of this procedure.

2. Research has demonstrated that the same benefits from gingival

curettage can be derived from thorough periodontal instrumentation

and meticulous plaque control. Thus, curettage is no longer a

recommended periodontal surgical procedure.

B. Although the gingival curettage is no longer recommended as a

periodontal surgical procedure, some clinicians advocate performing

gingival curettage with chemicals or lasers that destroy the pocket lining.

At present, these types of gingival curettage are not part of mainstream

periodontal therapy, but much more research on the use of lasers in

periodontal therapy is needed to clarify this confusing area.

2. Indications. Gingival curettage is not recommended as part of modern

periodontal therapy.