GINGIVECTOMY – GINGIVOPLASTY
- Definition :
For Lindhe: “Gingivectomy is a surgical technique that aims to eliminate the soft tissues of the pocket, it is differentiated from gingivoplasty which is intended to remodel the gum to give it an aesthetic and functional morphology. Gingivectomy is therefore a gingival excision by incision followed by excision (plasty), and depending on the type of incision we speak of GBI or GBE.”
- Place of gingivectomy in the treatment plan:
→ Initial preparation: the gingivectomy will be performed after the initial treatment phase which includes:
– Motivation for oral hygiene.
– Teaching brushing methods.
– Descaling, surfacing.
– Restoration of the oral cavity.
→ Reassessment phase:
– Periodontal surgery can only be performed after a good tissue response to the initial treatment and good patient cooperation.
→ Corrective phase:
– Gingivectomy is a surgical treatment that is part of the corrective phase.
- Indications and contraindications:
- Indications for GBE:
∙ False pocket: resulting from gingival hypertrophy or hyperplasia:
→ Hypertrophic gingivitis of inflammatory origin.
→ Conditioned gingivitis:
Through mouth breathing, hormonal disorders, or linked to taking certain medications.
→ Hereditary gingival hyperplasia.
∙ Sufficient attached gingival height: this height must be assessed so as to be able to support a reduction without endangering its protective role, in order to maintain periodontal health and prevent the appearance of gingival recessions.
∙ The texture of the marginal gingiva: it must be thick, fibrous and the gingival volume increase in height.
∙ Supra-bony pockets: not extending beyond the mucogingival line associated with gingival hyperplasia.
2- Indications of GBI:
∙ Hypertrophic gingivitis: fibrous texture with insufficient attached gingival height.
∙ Supra-bony pockets: shallow.
3- Contraindications:
a- General CI:
∙ Absolute:
– Leukemia, Hemophilia, Irradiated patients, heart disease (life-threatening risk): Osler’s endocarditis, Congenital heart disease, valvular and vascular prosthesis.
– Agranulocytosis, Multiple sclerosis, PARKINSON’s disease.
– Unmotivated patient.
∙ Relatives:
– HTA, angina pectoris, diabetes, patient on anticoagulant, pregnant woman, nervous and anxious patient, sedative premedication.
b- CI specific to techniques:
∙ The GBE:
– Thin marginal gingiva of soft consistency.
– Insufficient attached gingival height.
– Suprabony pockets that extend beyond the mucogingival line.
– Thickening of the edges of the alveolar bone.
– Infra-bony pockets.
∙ The GBI:
– Soft gum consistency.
– Infra-bony pockets.
-Bone defects.
GINGIVECTOMY – GINGIVOPLASTY
- Advantages and disadvantages:
Advantage :
– Simple technique.
– Good visual access ⇒ treatment safety.
– Complete elimination of pockets.
– Stable and predictable morphological results.
Disadvantages:
– Limited indication.
– Large wound ⇒post-operative pain.
– Exposure of the neck of the tooth (sensitivity – risk of decay).
– Risk of exposing the bone.
– Constant aesthetic damage.
- Instrumentation:
Standard tray: Mirror, tweezers, explorer probe, periodontal probe.
Tray for technique:
– Crane Kaplan marking tweezers
– Disposable scalpel handle: Hard Parker, Blake Waerhaug.
– Gum scissors, peeler, suction cannulas, irrigation syringe.
Additional equipment: Surgical field, gloves, mask, anesthesia, syringe, physiological serum, H2O2 , compresses, scaling and curettage instruments .
GINGIVECTOMY – GINGIVOPLASTY
- Surgical techniques:
1-The GBE technique:
a- Psychological preparation.
b- Asepsis of the operating field.
c- Local anesthesia:
d- Supplementary anesthesia: additional injections can be performed at the level of the interdental papillae.
e- Pocket marking: using the CRANE KAPLAN tweezers, the level of the epithelial attachment is assessed for each tooth in relation to the marginal edge of the gum. The instrument is held so that the tip is in a straight line with the vertical axis of the tooth.
f- Primary incision: the incision begins at the level of a papilla, approximately 2 to 4 minutes apically to the bloody points that mark the base of the pockets. It is performed with a No. 11 or 15 blade inclined at 45° in the coronal direction up to the dental contact to reach the base of the pockets.
The incision is clean and continues while maintaining contact with the root; the incision line can be continuous or discontinuous.
g- The secondary incision: (intra-sulcular) it is extended into the inter-proximal spaces performed with a No. 15 blade or ORBAN ½, WAERHAUG ½ scalpel and joining the 1st incision and following the shape of the dental neck.
This incision allows the separation of the gingival festoon from the underlying connective tissue.
h- removal of the gingival festoon: once the incisions are completed, the excess gingival tissue is detached using a thick-bladed instrument such as a curette for example.
i- curettage and surfacing:
– Curettage of the granulation tissue in the interdental spaces with a curette so that the hemorrhage does not obscure the scaling operation.
– Subgingival scaling with ultrasound or a manual instrument.
– Surfacing + polishing of root surfaces.
j- Gingivoplasty: the gingival surface is regularized using a COSTAVEJO chisel and the angle formed by the incision is rounded.
k- Washing with physiological serum
l- Good hemostasis by compression
m- You have to check each face of each tooth
n- The application of the dressing which is used to:
– Reduce pain.
– Control post-operative bleeding.
– Minimize the possibilities of infection occurring.
– Facilitate healing by preventing trauma during chewing.
– It should be checked that it does not create occlusal interferences, it is renewed after 7 days and kept for 14 days.
o- Drug prescription and post-operative advice:
Healing:
The surface is quickly covered with a clot and the underlying tissue is infiltrated with inflammatory cells, the epithelial cells increase in number at the edge of the wound and they migrate to the connective surface after 7 days, it will be epithelialized from the 8th day , the new groove is formed by occlusal proliferation of the connective tissue, keratinization occurs around the 14th day but epithelialization of the groove and the maturation of a new attachment does not occur until around the 35th day ⇒ healing by 2nd intention is obtained .
2- GBI technique: GRANT in 1979 defined “reverse bevel” or “internal bevel” gingivectomy as excision of the gum by means of a flap, for them it is a technique allowing curettage – open subgingival surfacing without bone exposure.
a- Psychological preparation.
b- Asepsis of the operating field.
c- Anesthesia.
d- Marking the pockets.
e- Incision I area : incision line made with a No. 11 blade must start 1 minute from the marginal edge, coronally/at the bleeding points.
– The scalpel penetrates the gum tissue up to the bony crest at an angle of 10° to 30° with the axis of the tooth depending on the thickness of the gum and the depth of the pocket.
– The incision follows the contour of the teeth, in the interproximal spaces, it must preserve the papilla as much as possible, the outline of this incision must allow the papillae to come together and avoid the formation of gingival craters.
f- Secondary incision: to facilitate the removal of the gingival collar.
– Thicken the gum on its inner surface + curettage and surfacing.
– Removal of granulation tissue using a curette, careful surfacing to remove infiltrated cementum and allow reattachment of epithelial-connective structures.
g- Washing and hemostasis.
h- Sutures: the 2 flaps are reapplied and held on the root surfaces by sutures (point by point) maintain pressure for 5 minutes on the flaps to prevent any risk of detachment.
i- Applying a dressing.
j- Post-operative advice.
Healing: this is first intention , since the gingival tissues have been perfectly applied to the dental surface at the end of the procedure, without the interposition of a clot and without exposing the bone, a new groove and a new attachment will form.
GINGIVECTOMY – GINGIVOPLASTY
3- Comparative table between the two techniques:
| GBE | GBI |
| – Indicated when the HGA is sufficient.- ↑ in volume in height – External bevel incision: the blade is inclined at 45° apically to the bleeding points.- Requires gingivoplasty.- Without stitches.- Healing by 2nd intention is slower in the short term/at GBI. | – Insufficient HGA.- ↑ in volume in thickness.- Internal bevel incision: the blade is inclined at 30° coronally at the bleeding points.- No gingivoplasty.- Stitches are performed.- First intention healing.- Presents a lavage/GBE: rapid hemostasis, immediate visualization of the future gingival contour, |
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