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. 1618). 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. 1619). 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 gingival 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 socalled "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 procedurebecause of enlarged gingivathen, 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.