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Gingivectomy and Gingivoplasty

Gingivectomy is the excisional removal of gingival


tLssue for pocket reduction or elimination. The
technique has, as its main advantages, simplicity,
and ease of mastery. Gingivoplasty is the reshaping of the gingiva to attain a more physiologic
contour that allows a gradual rise of tissue interproximally and a fall on the labial and lingual surfaces. In gingivoplasty, the tissue is thinned interproximaily to produce a more harmonious
contour, with interproximal sluiceways for the
easy passage of food. Gingivectomy and gingivoplasty are usually performed at the same time.

3.
4.
5.

Ease of pocket elimination


Good access
Favorable esthetic results

Disadvantages
1.
2.
3.
4.

Healing by secondary intention


Bleeding postoperatively
Loss of keratinized gingiva
Inability to treat underlying osseous deformities

Gingivectomy
Rationale

Presurgical Phase

1.
2.

Presurgical preparation is carried out to reduce


gross inflammation and remove local factors (calculus, plaque, or overchanging restorations). After
initial healing, the zone of attached tissue can be
assessed properly. At the time of operation, adequate local anesthesia is given. A vasoconstrictor
should be used for control of hemorrhage, especially since healing is by secondary intention.
Under anesthesia, the pockets are probed to
check their depth and to ensure that they do not
extend beyond the mucogingival junction (Figure 5-1 A). By sounding, the osseous topography
is determined and the need for osseous surgery is
determined (Figure 5-IB).
Gingivectotiiy is contraindicated if osseous
surgery is needed.

Pocket elimitiation for root accessibility


Establish physiologic gingival contours

Indications
1. Suprabony pockets
2. An adequate zone of keratinized tissue
3. Pockets greater than 3 tnm
4. When bone loss is horizontal and no need
exists for osseous surgery
5. Gingival enlargements
6. Areas of limited access
7. Unesthetic or asymmetric gingival topography
8. For exposure of soft tissue impaction to
enhance eruption
9. To facilitate restorative dentistry
10. To establish physiologic and gingival contours
post-acute necrotizing ulcerative gingivitis
and flap procedures

Contraindications
1.
2.
3.
4.
5.
6.
7.
8.

An inadequate zone of keratinized tissue


Pockets that extend beyond the mucogingival
line
The need for osseous resection or inductive
techniques
Highly inflamed or edematous tissue
Areas of esthetic compromise
Shallow palatal vaults and prominent external
oblique ridges
Treatment of intrabony pockets
Patients with poor oral hygiene

Pocket Marking
A pocket marker or periodontal probe is used to
outline the base of the pockets with a series of
small bleeding points (Figure 5-1C). Three points
(mesial, distal, and buccal) are marked on each
buccal and lingual surface. These marks delineate
the pocket wall to be removed.
The pocket marker is placed into the pocket
and held parallel to the tooth. When the base of
the pocket is reached, the tissue is marked (Figure
5-lD). Once the bleeding points have been established, they form a dotted line that outlines the
incision. The pocket marker must not be tilted or
the incision will be too deep or too shallow (see
Figure 5-ID).

incisions
Advantages
1.
2.

Predictability
Simplicity

Incisions may be continuous (Figure 5-1, E, H, I)


or discontinuous (Figure 5-1, F, G). Both incisions are begun on the most terminal tooth and

are continued around until the incision is cotnplete. No real differences exist between incisions
except that one is an interrupted incision ending
in the papillary area of each successive tooth until
the incision is completed.
Incisions can be made with scalpels or gingivectomy knives, although the gingivectomy
knife is easier to use because of the anguiation and
shape of the blade. The heel of the knife is used for
the pritnary incision, which begins just apical to
the bleeding points (Figure 5-U). The blade is
held in such a manner that the incision is as close
to the bone as possible for total pocket removal
and production of a tissue bevel of 45. The blade
must pass fully through the tissue to the tooth.
An Orban or Kirkland interproximal knife is
used to free the tissue interproximally. It is placed
interdentally at a 45 angle both buccalty and lingually until the tissue Is freed (Figure 5-1, K and
L). The knife also engages the tooth to free the tissue at the line angle. If the incisions have been
made properly, the tissue can be removed in one
step. Figure 5-lM shows the correct and incorrect
incision placements.
Once free, the tissue is removed by using a
hoe or heavy sealers (Figure 5-IN). Small sealers
and curets are now used for scaling and root
planing to remove residual granulation tissue,
calculus, and soft cementum (Figure 5-10).

Gingivopiasty
The final contour of the tissue is established using
scissors, tissue nippers, or diamond stones (Figure
5-1, P and Q). This final contouring, or gingivoplasty, is used to thin the tissue on the interradicular surface and establishes a more fluid contour.
The healed tissue (Figure 5-lR) will be thin, with
a scalloped architecture that flows smoothly from
the interdental areas onto the interradicular surfaces for easy passage of food.
The complete procedure s outlined clinically in Figure 5-2, and the results that can be
attained are shown in Figure 5-3.

Edentulous, Retromolar,
and Tuberosity Areas
The edentuious area between the teeth is noteworthy only in that the incision should stretch
the entire length of the space. Pockets tend to reform if the incision is limited to an area adjacent
to the teeth (Figure 5-4).

40 Basics

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FIGURE 5-1. Gingivectomy technique. A, Enlarged gingival tissue with pocketing. S, Horizontal bone loss. C, Use of pocket markers to establish bleeding points for
incisions. D, Correct and incorrect placement of pocket markers and how incisions are affected: 1 = correct marking with a beveled incision to the base of the pocket; 2 = incorrect shatlow marking, resulting in incision above the base of the pocket: and 3 = incorrect deep incision, resulting in bone exposure and possible removal
of all attached gingiva. , Continuous incision on the buccal aspect. Note how incisions follow the outline of bleeding points. F, Discontinuous incision. G, Palatal incision. Note that the incisai papilla (ip) is outlined or avoided in this area. H, Continuous incision extending from the tuberosity area onto the buccal aspect of the teeth.
/. Continuous incision on the palatal surface.

Gingivectomy and Gingivopiasty

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FIGURE 5-1. continued. J. Periodontal knife angulated at 45, foilowing the continuous incision outline. K, Interpfoximai knife used to sepafate and detach tissue buccoiingually. L. Pfoper anguiation of an intefpfoximal knife to pefmit soft tissue coverage. M. Incision. 1 = coffect incision beveled above bone to the base of the pocket; 2 = incorrect incision: there is no bevel and the incision is too deep, resulting in bone exposure; 3 = incorrect shallow incision, resulting in failure to remove the
pocket; and 4 = incomplete incision because of failure to carry the incision to the tooth, resulting in ragged, torn tissue. N, Removal of excised tissue with a hoe or
heavy sealers. 0. Sealers and curets are now used to remove residual granulation tissue (1) and subgingival plaque and calculus (2). P and Q, Gingivopiasty is now
completed using tissue nippers and diamond stones to establish a thin, even-flowing gingival architecture that has a scalloped outline rising interproximally to a conical shape. R. Final healed tissue.

42 Basics

FIGURE 5-2. Gingivectomy and gingivoplasty procedures. A, Before treatment, , Bleedifig points show marked pockets- Probe shows 4 to 5 nnm pockets. C. Initial
incision with a periodontat knife angled at 45. D, A no. 15 scalpel blade used for the initial incision. E, Orban knife used to release interdental tissue. F, Heavy scaiers
used to remove incised tissue. G. Tissue removed. Note the ledge of beveled tissue. H, Scissors used for reduction of the ledge and gingivoplasty. /. Small diamonds
are used to blend the tissue, especially interproximally on bulky tissue. J, Tissue nippers may be used for gingivoplasty. Note how tissue has been thinned and blended (K). L, Healed tissue 6 months later.

Gingivectomy and Gingivoplasty

FIGURE 5-3. Results obtained by gingivectomy. A to D, Before. A' to D\ After. Note how the teeth have come together
in D'.

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4 4 Basics

Incorrect

Correct

Incorrect

FIGURE 5-4. Treatment of edentulous areas. A. Outline of a correct incision to treat the total edentulous space. S, Healed ridge with no residual
pockets. C, Incorrect incision, which treats only pockets adjacent to teeth. D, Residua! pockets or depressions remain after treatment.

The retromolar (Figure 5-5) and tuberosity


(Figure 5-6) areas are blended with the buccal and
lingual (palatal) incisions. In the retromolar area,
a gingivectomy is done only if there is adequate
keratinized tissue distal to the tooth. The incision
is fiat or beveled to the base of the pocket.

1.
2.
3.
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5.

Common Reasons for Failure

6.

Wade outlined 15 reasons whygingivectomes fail,


most of which are still valid today:

7.

Unsuitable case selection: cases with underlying osseous irregularities or intrabony detects
Incorrect pocket markings
Incomplete pocket elimination
Insufficient beveling of the incision
Failure to remove tissue tags, resulting in
excessive (granulation) tissue
Failure to remove etioiogic factorscalculus
and plaque
Beginning or terminating the incision in a
papilla

8.
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10.
U.
12.
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15.

Maxillary
Tuberosity

Mandibular
Retromolar Area

FIGURE 5-5. Treatment of a


mandibular retromolar area.
T"
A, A periodontal knife is used to
blend the buccal and lingual incisions
about the distal aspect of the last molar if enough keratinized attached gingiva is present. S, Retromoiar
area reduced and blended with other incisions.

Failure to eliminate or control the predisposing factors


Inaccessible interdental spaces
Loose dressings
Lost dressings
Insufficient use of dressings
Failure to prescribe stimulators or rubber
tipping for interproximal use
Failure to use stimulators or a rubber tip
Failure to complete treatment

FIGURE 5 ^ . Treatment of maxillary tuberosity. A. A periodontal


knife is used to level and remove
tissue distal to the molars when
no furcation involvement or osseous
irregularities exist. S, Tuberosity tissue
removed and blended with other incisions