What is gingivectomy:
The term gingivectomy means excision of gingiva (Gingiva means the gum, which is the area around the root of a tooth.The gingiva is attached in part to the cementum of the tooth and in part to the alveolar bone. The gingiva is composed of mucosa that is designed for chewing) to provides visibility and accessibility of the periodontal pocket for complete removal of irritating surface deposits and through smoothing of the roots.
By removing diseased tissue and local irritants it also create a favorable environment for surgical healing and the restoration of physiological gingival contour.
Indications:
1. Elimination of suprabony (coronal to crestal bone) pockets, regardless of their depth, if the pocket wall is fibrous.
2. Elimination of gingival enlargement.
3.Elimination of suprabony periodontal abscess.
Contraindications:
1. The need for bone surgery, even for examination of the bone shape and morphologic features.
2. The location of the bottom of the pocket apical to the mucogingival junction.
Techniques for gingivectomy:
1. Surgical gingivectomy.
2. Gingivectomy by chemotherapy.
3. Gingivectomy by electrosurgery.
SURGICAL GINGIVECTOMY:
The procedures are as follows:
1. Pockets marking.
2. Resection of the gingiva.
3. Removal of the marginal and interdental gingiva.
4. Appraise the field of operation.
5. Removal of the granulation tissue and calculus.
6. Perform hygiene procedure.
7. Placement of the periodontal pack.
1. Marking of the pockets:
# Pockets surface are explored with pocket marker.
# Pockets are marked with a pocket marker. The instrument is held with the marking end in line with the vertical axis of the tooth.
# The straight end is inserted to the base of the pocket.
# The level is marked pressing the pliers together and producing a bleeding point on the outside surface.
Marking starting on the distal surface of the last tooth moves to the facial surface and proceeding anteriorly to the mid line.
# The procedure is repeated on the lingual (tooth surface next to your tongue) surface. Each pocket is marked in several areas to out line it's course on each surface.
2. Resection of gingiva:
a) Choice of instrument: Based on individual experiences-
i. Periodontal knives-For incision on facial and Ingual surface and distal to the terminal tooth.
ii. Orban periodontal knives-For supplimental interdental incision,
iii. B. P. blades no. II, 12 and scissors- For auxiliary use.
b) Incision: Depends upon operators preference
i. Discontinuous or continuous incision for lingual and facial surface,
ii. Distal incision for distal surface of the last tooth.
Discontinuous incision:
# Start on the facial surface at the distal angle of the last teeth, carried forward, following the course of the pocket and extending through the interdental gingiva to the distofacial angle of the next tooth.
# The next incision is begun where first one cross the interdental space, and is carried to the distofacial angle of the next teeth.
# Individual incisions are repeated for each tooth to be operated on.
Continuous incision:
Start on the facial surface of the last tooth, carried forward without interruption, following the course of the pockets.
# The procedure is repeated on teh lingual surface.
# To avoid blood vessels and nerves of the incisive canal and also to produce a better postoperative gingival contour, the incision should carried along the side of the incisive papilla, not horizontally across it.
Distal incision:
# Incision situating on the distal surface of the last eruptive teeth and connective the facial and lingual incision is called distal incision.
# It is made with a periodontal knives, inserting below the bottom of the pocket and is beveled so that it blends with the facial and lingual incision.
How to make the incision:
1. The incision is started apical to the points marking the course of the pockets and
2. Is directed coronally to point between the base of the pocket and the crest of the alveolar bone.
3. Incision should be as close as possible to the bone, without exposing it, to remove the soft tissue coronal to the bone.
4. Incision should be beveled at pap proximately 45 degree to the tooth surface.
5. The incision should recreate the normal festooned pattern of the gingiva as far as possible, but not if this means leaving part of the pocket wall intact.
6. The incision should pass completely through the soft tissue of the teeth.
7. If the incision seems to be inadequate, it should be corrected.
Teeth adjacent to the edentulous areas:
I) The usual incision are made on the facial and lingual surfaces.
II) In addition, a single incision is made across the edentulous ridge apical to the pockets on the teeth and close to the bone. If we excise the pocket separately, this will create gingival troughs. (Fig- 9).
3. Removal of the marginal and interdental gingiva:
I) Start from the distal surface of the last eruptive teeth.
II) Detach it from the incision line with hoes and scalars.
III) Place the instrument deep in the incision in contact with the teeth surface and moves coronally with a slow, firm motion.
4. Appraise the field of operation:
After the pocket wall is excised and the field is cleaned, the following features should be observed-
I) Bead like granulation tissue.
II) Calculus remnants closed to the pocket where it was attached.
III) Band like light zone on the root, where the base of the pocket was attached.
IV) Softening of the root surface due to cellular resorption and cementum protuberance.
5. Remove the granulation tissue and calculus:
I) Remove the granulation tissue first by a curettage, so that hemorrhage from granulation tissue does not obscure the scaling operation. The curettage is guided along the tooth surface and under the granulation tissue, so that it is separated from the underlying bone. Removal of granulation tissue reveals either the surface of the underlying bone or a covering field of fibrous tissue.
II) Remaining calculus and necrotic cementum are removed and root surface is smoothed with a sealer and curettes.
6. Oral hygiene maintain and periodontal pack replacement:
I) Cheek every tooth surface for caluclus and other soft tissue.
II) Wash the area several times with warm water.
III) Cover the area with a gauze sponge folded in a U-shaped, and instructs the patient to bite on the pack until the bleeding stops.
Cautions:
I) Persistent bleeding should stop with a pled jet of cotton saturated with hydrogen peroxide. Because it interferes with adapation and setting of pack.
II) A moderate type of clot should have to be developed before pack applied. Because it protects the wound and provides a scaffolding for the new blood vessel and connective tissue.
III) Excessive clot should be avoided, because it interfere with retention of pack and provide excellent media for bacterial growth.
What is gingivoplasty:
Artificial reshaping the gingiva to create physiological gingival contours is termed gingivoplasty.
Indications:
To correct the deformaties in the gingiva that interfere with normal food excretion, collect irritating plaque and food debris, prolong and aggravate the disease process. The deformaties are-
1. Gingival clefts and crater.
2. Shelf like interdental papilla caused by acute necrotizing ulcerative givgivitis and
3. Gingival enlargement.
Instrument:
Periodontal knife, a scalpel, rotatory coarse diamod stones.
Technique: Similar to gingivectomy.
Procedures involves:
I) Tapering the gingival margin.
II) Creating an escalloped gingiva.
III) Thinning the attached gingiva.
IV) Creating vertical groves and
V) Shaping the interdental papilla to provide sluiceway for the passage of food.
Difference between gingivoplasty and gingivectomy:
Gingivectony is performed to eliminate periodental pocket and includes reshaping as part of the technique. Gingivoplasty is done with the sole purpose of recontouring the gingiva in the absence of pocket.
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