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45

Gingivectomy
Shalu Bathla

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Historical Perspective
Definition
Objectives
Indications
Contraindications
Limiting Circumstances
Drawbacks

HISTORICAL PERSPECTIVE
History of gingivectomy can be dated back to 1742, when
Fauchard describe the procedure to remove excessive
tissue. Robicsek in 1884, later on described the so called
gingivectomy procedure as straight incision technique
in which the tissues were excised and the granulation
tissue eliminated. Pickerills book Stomatology in
General Practice, published in 1912, described the
procedure and very reasonably named the operation
gingivectomy. Zentler in 1918 gave scalloped incision
technique for gingivectomy. Gingivectomy is thought to
be introduced as an official periodontal therapy when
the idea of periodontal etiology shifts from bone to soft
tissue. This is mainly due to Kronfeld in 1935, who
emphasized that periodontal disease is not the disease
of the bone. Gingivectomy was later defined by Grant et
al in 1979 as being the excision of the soft tissue wall of a
pathologic periodontal pocket.

8. Gingivoplasty
9. Types of Gingivectomy Procedure
Surgical Gingivectomy
Laser Gingivectomy
Gingivectomy by Electrosurgery
Gingivectomy by Chemosurgery
10. Healing After Gingivectomy

OBJECTIVES
i. Pocket elimination by gingival resection.
ii. Development of physiologic tissue form for disease
prevention.
INDICATIONS
i.
ii.
iii.
iv.

Elimination of suprabony pockets.


Elimination of gingival enlargement.
Elimination of suprabony periodontal abscess.
To expose additional clinical crown to gain added
retention for restorative purposes and to provide
access to subgingival caries.
v. The presence of furcation involvement (without
associated bone defects) where there is a wide zone
of attached gingiva.
vi. Pericoronal flap.
CONTRAINDICATIONS

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

i. The need for bone surgery or examination of the bone


shape and morphology.
ii. Situations in which the bottom of the pocket is apical
to the mucogingival junction, gingivectomy will

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excise most of the gingiva and leave an inadequate


zone of gingiva.
iii. Esthetic considerations, particularly in anterior
maxilla.
iv. If the patient complains of tooth senstivity before
surgery. Although it is relative contraindication, as
the cause of any complaint should be treated before
the surgery and if the sensitivity cannot be
controlled, surgery should be contraindicated.

PERIODONTICS REVISITED

LIMITING CIRCUMSTANCES
1. Palatal aspects of maxillary posterior teeth: When the
palatal vault is shallow and the depth of periodontal
involvement is near or enters the vault area,
gingivectomy on the palatal aspect of maxillary
posterior teeth may result in elimination of most if
not all of the palatal gingiva, placing the gingival
margin at or near a level of coincident with that of
the roof of the mouth.
2. Mandibular retromolar lesions: When an incision is
made on movable and delicate mucosa, this tissue
often cuts poorly, bleeds profusely and may be
difficult to resect and shape. The use of the distal
wedge procedure, often simplifies the management
of retromolar tissue.
3. Maxillary tuberosity areas: When soft tissue is so great,
relative to the depth of periodontal involvement on
the distal aspect of the last molar, that its level
resection would bring about surgical entry into the
mucosa of the hamular notch. It may be more
appropriate to perform a distal wedge procedure to
eliminate diseased tissue immediately adjacent to the
distal portion of the molar.
4. Cases of emotional stress: With age, diminish patient
cooperation and motivation, retarded healing, etc.
have a direct bearing upon the desirability of the
surgical therapy. Such patient is a poor surgical risk
and 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 be
eliminated. Thus, attached gingiva is wasted.
4. Clinical crown are lengthened considerably and need
to be explained to the patient before surgery.

5. It may lead to dentin hypersensitivity due to root


exposure.
GINGIVOPLASTY
Gingivoplasty first described by Goldman in 1950 as a
plastic procedure of which the gingival tissue was
removed. Sugarman in 1951 describe electrosurgical
gingivoplasty in his case report. Gingivoplasty can be
defined as recontouring of gingiva that has lost its
physiologic form. Gingivoplasty was introduced to
facilitate dealing with abnormal form of gingiva and was
essentially a surgical procedure designed to reshape
gingiva without necessarily reducing sulcular depth.
The purpose of gingivoplasty is different from
gingivectomy, as gingivoplasty is just reshaping of
gingiva to create physiologic gingival contours, with the
sole purpose of recontouring the gingiva in the absence
of pockets, while the objective of gingivectomy is to
eliminate pocket.
Indications of gingivoplasty:
i. Need for correction of the grossly thickened gingival
margin.
ii. Gingival clefts and craters caused by necrotizing
ulcerative gingivitis that interfere with normal food
excursion, collect plaque and food debris.
iii. Sharply varying levels of gingival margin in adjacent
areas.
iv. Saucer shaped deformities, buccolingual in the
interproximal regions.
Instruments: Gingivoplasty may be done with a
periodontal knife, scalpel, rotary coarse diamond stones
or electrode.
Steps in the gingivoplasty procedure are similar and
resembles those performed in festooning artificial
dentures 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 for
the passage of food.
Scrapping: Use a scalpel as a hoe and pass the instrument
tightly but firmly over a firm, tough tissue surface which
results in shaving of the surface. The use of rotary abrasives
consists essentially of abrading tissue until it has assumed
the desired form. The rules governing the application of
the rotary abrasive to soft tissue are exactly those that apply
to hard tissue. A steam of water on the instrument

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

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CHAPTER 45: Gingivectomy . d349

expediates the procedure immeasurably just as it does on


bone, enamel or dentin. Accelerated speed ensures a
smooth, rapid operation while the stream of water provides
temperature 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)

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

Surgical handle: Bard Parker no.3 or angulated


handle (Blakes handle) with blade no 11,12,15
Curettes
Tissue nipper (Fig. 45.2), scissors.
Procedure

Laser Gingivectomy

Fig. 45.2: Tissue nipper

The lasers most commonly used for gingivectomy are


the CO 2 having wavelength of 10600 nm and
Neodymium:yttrium-Aluminium-garnet (Nd:YAGtr)
having wavelength of 1064 nm both in infrared range.

PERIODONTICS REVISITED

Mark bleeding points: After LA is given in the selected


site, mark bleeding points with the help of pocket
marker systematically, beginning on the distal surface
of the tooth, then on the facial and mesial surface.
The procedure is repeated on the lingual/palatal
surface. Beak of pocket marker must be parallel to
root surface. Pinpoint perforations individuate pocket
depth which is used as a guideline for the incision.
Incisions: Discontinuous/continuous incision is given
apical to the bottom of the bleeding point beginning
at the most terminal tooth (Fig. 45.3). External bevel
incision is given at an angle of 45 apical to the base
of the pocket with the help of Kirkland knife or blade
no.11 or 15 with BP handle no.3 or angulated Blakes
handle. The blade must pass fully through the tissue
to the tooth in coronal direction (Figs 45.4 and 45.5).
The incision should be as close as possible to the bone
without exposing it so as to remove the soft tissue
coronal to the bone. The main principle here is to
eliminate pocket all the way to the base without
exposing the bone. Once the primary incision is
completed on the buccal and lingual aspect, Orbans
knife or Waerhaug knife is placed at angle of 45 to
free the tissue interproximally.
Tissue removed: The incised tissues are carefully removed
with the help of curette or scaler. The remaining tissue
tabs are removed with scissors. The gingival margins
should be thin and beveled and if necessary corrected
by means of knives or rotating diamond burs.
Scaling and root planing: The calculus and necrotic
cementum on the tooth are removed with the help of
scalers and curettes.
Periodontal dressing: Bleeding is controlled and after
that periodontal dressing is applied over the treated
site primarily for patient comfort. Thereafter, patient
is given postoperative instructions.

Advantages
i. Laser offers an almost completely dry, bloodless
surgery.
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.

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

Disadvantages
i. There is loss of tactile feedback in using the
instrument.
ii. It is imperative that all operating room personnel
wear 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 from
0.0075 inch to 0.015 inch), small ovoid loop/diamond
shaped electrodes.

PERIODONTICS REVISITED

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

Procedure: The site must not be too dry otherwise


excessive sparking will result. Conversely, if excessive
moisture is present, considerable surface coagulation will
occur instantly. For the best results, the site should be very
slightly moist. The removal of gingival enlargements and
gingivoplasty is performed with the needle electrode,
supplemented by the small ovoid loop/ diamond shaped
electrodes for festooning. A blended cutting and
coagulating (fully rectified) current is used. In all
reshaping procedures, electrode is activated and moved
in a concise shaving motion. Electrode should be kept in
constant motion in order to prevent a build-up of heat
with appropriate current setting and the patient should
be properly grounded. Clean all debris from electrodes
with gauze sponges after each movement through soft
tissue. The sponge may be dry or moistened with absolute
isopropyl alcohol.
Advantages

Figs 45.5A and B : (A) Incorrect incisions: 1. Shallow incision (Fail to


remove pocket), 2. No bevel incision (Result in bone exposure); (B)
Correct incision

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.

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

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CHAPTER 45: Gingivectomy . d351

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

has been shown to occur during this phase. Gingivoplasty


wound often heal faster than gingivectomy wound.
2nd day
4th day

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.

6th day

Contraindication

16th day

21st day

One major contraindication to electro-surgery is a cardiac


pacemaker. Since an electrosurgical unit generates
radiofrequency energy, it should never be used within
15 feet of an individual with a cardiac pacemaker.
Gingivectomy by Chemosurgery
Five percent paraformaldehyde or potassium hydroxide
were the chemicals used to perform gingivectomy which
is no longer in use because of the following
disadvantages 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 fiber
system are slower in chemically treated gingival
wounds than in those produced by scalpel.
HEALING AFTER GINGIVECTOMY

The tissue changes that occur in post gingivectomy


healing are the same in all individuals, but the time
required for complete healing varies, depending upon
the 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 the
tooth surface in apicocoronal direction.
Gingivectomy wound heals by secondary intention.

POINTS TO PONDER
9 Failure to produce beveled incision leaves a broad
plateau which takes more time than ordinarily
required to develop the physiologic contour of
gingiva, thus the incision should be beveled at
approximately 45 to the tooth surface.
9 The granulomatous tissue is removed first and then
thorough scaling is attempted on the tooth, so that
hemorrhage from the granulomatous tissue should
not 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 restorative
dentistry. Dent Clin North Am 1980;24(2):247-69.
3. Genco RJ, Rosenberg ES, Evian C. Periodontal surgery. In, Genco
RJ, Goldman HM, Cohen DW. Contemporary Periodontics. CV
Mosby 1999;554-84.

PERIODONTICS REVISITED

Healing after gingivectomy is by secondary intention.


Bernier J and Kaplan H reported the following time
sequence for healing following gingivectomy in humans.
The initial response after gingivectomy is the formation
of a protective surface clot; the underlying tissue becomes
acutely inflamed with some necrosis.
The outer epithelium heals by approximately 14
days but sulcular epithelium requires 3 to 5 weeks to
heal. Twelve hours after gingivectomy there is slight
reduction in cementoblasts and some loss of continuity
of the osteoblastic layer on the outer aspect of alveolar
crest. New bone formation occurs at the alveolar crest
as early as the 4th day after gingivectomy and new
cementoid appears after about 10 to 15 days.
Thus, total gingivectomy healing takes place in about
4 to 5 weeks and remodeling of the alveolar bone crest

Clot formation

Clot replaced by granulation tissue


Epithelium without rete pegs extends over part
of the surface
Dense inflammatory infiltration

Wound is covered by stratified squamous


epithelium
Collagen formation starts in the connective tissue

Epithelium with rete pegs appear


Dense collagenous connective tissue appears

Epithelial rete pegs well developed, with


thickening of stratum corneum
Increased Collagen formation in the connective
tissue
Gingiva clinically appear normal

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

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4. Gingivectomy and Gingivoplasty. In, Grant DA, Stern IB,


Listgarten MA. Periodontics 6th ed CV Mosby Company
1988;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 use
of the CO2 laser for the removal of Phenytoin hyperplasia. J
Periodontol 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: Access
Therapy. In, Lindhe J, Karring T, Lang NP. Clinical
Periodontology and Implant dentistry, 4th ed Blackwell
Munksgaard 2003;519-60.

MCQs

PERIODONTICS REVISITED

1. Which of the following about conventional


gingivectomy is false?
A. Eliminate false pockets
B. Heal by secondary intention
C. Leads to decrease in the width of attached gingiva
D. Provides accessibility to alveolar bone

2. Gingivoplasty is more likely to be useful in:


A. NUG
B. Juvenile periodontitis
C. Desquamative gingivitis
D. All of the above
3. Indication of gingivectomy is:
A. Pocket depth below mucogingival junction
B. Infrabony pockets
C. 5 mm periodontal pocket
D. A fibrotic area of the free gingiva that covers part
of the occlusal surface of tooth
4. External bevel incision is beveled at approximately
_______ to the tooth surface.
A. 15
B. 30
C. 45
D. 90
5. Gingivectomy wound basically heals by:
A. Secondary intention
B. Primary intention
C. Tertiary intention
D. None of the above
Answers
1. D

2. A

3. D

4. C

5. A

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