Gingivectomy

Gingivectomy

Plan

-Introduction

1-Definitions

Gingivectomy, papiellectomy, gingivoplasty

2-History

3-Goals

4-Indications

5-Contraindications

6-Advantages

7-Disadvantages

8-Operating techniques

9-Precautions

10-Post-operative care

11-Other gingivectomies

12-Healing

Conclusion

Bibliography

Introduction: It is interesting to note that from a historical point of view, the first surgical techniques described in periodontics were aimed at providing access to diseased root surfaces. This could be achieved without excision of the soft tissue wall of the pocket “operation under visual control”. Later, methods were described that involved excision of the “diseased gingiva” gingivectomy.

1-Definitions:

-Gingivectomy The term gingivectomy represents the excision of the gum. It is actually a two-stage operation which consists on the one hand of removing the affected gum and on the other hand of scaling and polishing the root surfaces. We distinguish between:

Internal bevel gingivectomy is used to treat hypertrophies in the presence of low attached gingiva. It removes excess gingiva by thinning.

External bevel gingivectomy which consists of removing excess free gingiva by gingival eviction.

– Papillotomy : It consists of the excision of the interdental papillae

-Gingivoplasty : it is the artificial remodeling of the gum aimed at creating physiological gingival contours. It is the correction of the gingival anatomy in order to obtain the normal configuration of a gingival tissue. This correction will be done interdentally where it is a question of restoring a normal deflection.

We will use a D’Orban or Kirkland scalpel, a regular blade or fine scissors.

2-History:

-The surgical approach as an alternative to subgingival scaling in the treatment of pockets was already accepted at the end of the 19th century, when Robicsek (1884) introduced the so-called “gingivectomy” method.

-Gingivectomy was later defined by Grand et al. (1979) as “the excision of the soft tissue wall of a pathological periodontal pocket”. -The surgical method whose goal was to eliminate the pockets was usually associated with a remodeling of the diseased gingiva in order to re-establish a physiological architecture.

-The method of gingivectomy as it is used today was described by Goldman in 1951.

3-Goals:

-remove pathological tissues.

-visualize root surfaces and their deposits.

-rebalance or correct aesthetics.

– eliminate false periodontal pockets resulting from gingival hypertrophy.

4-Indications:

-gingival hypertrophy

-shallow suprabony pockets (3-4mm)

-fibrous gingival tissue.

-reaching bifurcations

-periodontal abscesses

-pericoronary hoods

Indications for papillectomy

It allows the lengthening of the clinical crown in the following cases:

-Proximal caries distant from the bone crest (at least 2mm).

-In prosthesis, slight lack of proximal height for a stump.

Removal of localized papillary hypertrophy or hyperplasia.

5-Contraindication:

-infrabony pockets

– muco-gingival problems, insufficiency of attached gingiva

– aesthetic and phonetic considerations.

– hemostasis problems, immune problems

-Poor hygiene.

6- Advantages:

-Easy and quick technique

-Visualization of lesions, therefore safety of treatment

-Predictable and stable results.

– Complete elimination of the pocket.

-no suture for GBE

-moderate postoperative pain for GBI

7-Disadvantages:

-limited indications

– constant aesthetic damage

-possibility of dentin hypersensitivity

– sometimes painful and long post-operative period.

For external bevel gingivectomy

– significant bleeding during the procedure

-second intention healing

8-Operating techniques:

-Truncal and local anesthesia , injection directly into the papillae is generally not necessary but sometimes useful. It is essential to use a surgical aspirator, it allows for good visibility of each root surface.

-Marking the pockets the pockets are probed at the level of each of their faces using a periodontal probe, and marked with the tweezers n° 27G. (Glickman). The tip of the instrument is in a straight line with the vertical axis of the tooth. The straight part is inserted at the base of the pocket. The level of the pocket is marked by pressing the two rods of the tweezers, and a bleeding point is made to appear on the external face. The process is repeated on the lingual face. Each pocket is marked in several places in order to delimit its outline on each face.

-Gingival resection : The gingiva can be resected with periodontal scalpels, a scalpel, or scissors. Periodontal scalpels No. 20G and 21G are used to make incisions on the vestibular and lingual surfaces and interdental periodontal scalpels No. 22G and 23G are used for interdental incisions.

Discontinuous and continuous incisions : The operator can make discontinuous or continuous incisions, depending on his preference.

The discontinuous incision begins on the vestibular surface at the distal angle of the last tooth, and continues following the outline of the pocket, passing through the interdental gingiva to the distovestibular angle of the adjacent tooth.

The next incision begins where the previous incision crosses the interdental space and continues to the disto-buccal angle of the next tooth. Each of these incisions is repeated until the midline is reached.

The continuous incision begins at the vestibular surface of the last tooth and continues without interruption following the contour of the pockets to the midline.

Distal incision

When the vestibular and lingual incisions are completed, they are joined by an incision made through the distal surface of the last erupted tooth. The distal incision is made using a #20 G or 21 G periodontal scalpel that is inserted under the bottom of the pocket and is beveled to join the vestibular and lingual incisions.

The incision should be made apically to the points that mark the outline of the pockets.

-removal of the marginal and interdental gingiva : from the distal face of the last tooth, the marginal gingiva is detached at the level of the line traced by the incision using surgical hoe no. 19G and supragingival scraper no. 3G and 4G, the instrument inserted deeply.

-removal of granulation tissue : Granulation tissue must be removed before starting a complete scaling, so that hemorrhage of granulation tissue does not obscure the scaling operation.

-removal of calculus and necrotic root substance : remove calculus and necrotic cementum and polish the root surfaces using supragingival and subgingival scrapers and curettes.

-Preparatory care for dressing : Before placing a periodontal dressing, each surface of each tooth should be checked for tartar or soft tissue debris; the area should then be rinsed several times with warm water and covered with a gauze sponge folded into a U shape. The patient is asked to bite the sponge, which remains in place until the bleeding stops.

-apply a periodontal dressing.

-Internal bevel gingivectomy technique

Anesthesia of the area to be treated
Clean the affected teeth
Performing eviction measurements with a periodontal probe

Make an incision with the #15 blade following the line of gingival scallops at an internal bevel.
Make the incision, leaving a space of 0.5 to 1 mm from the dental crown.
Make an intrasulcular incision in the treated area.
Peel off in full thickness with a thin peeler inserted into the internal bevel incision.
Make a horizontal incision to detach the coronal gingival band.
Remove the freed attached strip of gum using a curette.
Clean teeth using ultrasonic or manual instruments.
Reposition the redesigned flap through the scalloped internal bevel incision.
Make a series of hanging stitches

9-Precautions:

-do not leave any bones exposed

-apply a second dressing after a week.

10-Post-operative care:

-brushing non-operated teeth

-avoid hot and spicy food.

-prescribe mouthwashes

11-Other gingivectomy

By diamond wheels
By electrosurgery
By laser

12-Healing:

-the first reaction is the formation of a protective superficial clot , the underlying tissue undergoes acute inflammation accompanied by necrosis.

-the clot is then replaced by granulation tissue.

-after 12 or 24 hours, the epithelial cells bordering the wound migrate above the granulation tissue which they separate from the contaminated superficial layer of the clot.

-Marginal epithelial activity reaches its maximum within 24 to 36 h and surface epithelialization is completed after a period of 5 to 14 days.

-New cementoblasts appear after 10 to 15 days.

-After 24 hours, an increase in new connective tissue cells is observed just below the superficial layer of inflammation and necrosis. After 3 days, new young fibroblasts are deposited in this area.

-highly vascular granulation tissue grows in a coronal direction and creates a new marginal gingiva and a new sulcus.

-capillaries from the vessels of the periodontal ligament migrate into the granulation tissue, and within two weeks reattach to the gingival vessels.

Conclusion: Damage to the periodontal tissue determines the surgical procedure indicated, however all surgical techniques are contraindicated in cases of poor oral hygiene.

Bibliography:

-Bercy. Tenenbaum periodontology from diagnosis to practice DeBoeck University

-Francois Vigouroux practical guide to periodontal surgery Elsevier Masson SAS 62, rue Camille-Desmoulins 92442 Issy-les-Moulineaux Cedex September 2011

-Glickman clinical periodontology prevention diagnosis and treatment of periodontal diseases .

-Jan Lindhe manual of clinical periodontology CDP edition

-J.J.Barrelle Simon Hirsh introduction to periodontology publication AGECD 1973

– JF Tecucianu periodontal surgery EMC Paris styomatology 6-1978,23602 A-10.

Gingivectomy