Copy of GingivectomyPaul

GingivectomyGingivectomy

UIC College of DentistryUIC College of Dentistry

Dept. of Post-graduate Dept. of Post-graduate PeriodonticsPeriodontics

Paul JangPaul Jang

Objectives of the Objectives of the lecturelecture Should be able to discuss indications Should be able to discuss indications

and contraindications of gingivectomyand contraindications of gingivectomy Etiological factors of gingival Etiological factors of gingival

enlargementenlargement Surgical technique and steps involved Surgical technique and steps involved

in gingivectomy procedurein gingivectomy procedure Healing process after gingivectomyHealing process after gingivectomy How to prevent recurrence of gingival How to prevent recurrence of gingival

enlargementenlargement

Patient at presentation

Gingival EnlargementGingival Enlargement

Gingival EnlargementGingival Enlargement

Etiology:Etiology:

1.1. Plaque inducedPlaque induced

2.2. Drug-inducedDrug-induced

Drug-induced gingival Drug-induced gingival overgrowthovergrowth 3 commonly used drug types:3 commonly used drug types:

– Anticonvulsant used to treat epilepsy: Anticonvulsant used to treat epilepsy: Phenytoin.Phenytoin.

– Immunosuppressive agent used to Immunosuppressive agent used to prevent organ transplant rejection: prevent organ transplant rejection: Cyclosporine.Cyclosporine.

– Calcium channel blocker: Calcium channel blocker: Nifedipine.Nifedipine.(exact mechanism for all 3 drugs is (exact mechanism for all 3 drugs is

unknown)unknown)

Patient at presentation

8 6 8 8 6 9 8 4 76 4 9 8 7 10

GingivectomyGingivectomy

Definition: Definition: – Excision of the gingiva by removing Excision of the gingiva by removing

the diseased pocket wall that the diseased pocket wall that obscures the tooth surface.obscures the tooth surface.

– Provides visibility and accessibility Provides visibility and accessibility necessary for complete removal of necessary for complete removal of surface deposits and thorough surface deposits and thorough smoothing of the roots.smoothing of the roots.

Gingivectomy vs. Gingivectomy vs. GingivoplastyGingivoplasty GingivectomyGingivectomy

– To To eliminate periodontal pocketseliminate periodontal pockets and includes reshaping as part of the and includes reshaping as part of the technique.technique.

GingivoplastyGingivoplasty– To reshape and recontour the gingiva To reshape and recontour the gingiva

to create physiologic gingival to create physiologic gingival contours in the contours in the absence of pocketsabsence of pockets..

GingivectomyGingivectomy

Gingival Gingival overgrowthovergrowth

Other gingival Other gingival conditions conditions which require which require recontouringrecontouring

If access to If access to alveolar bone is alveolar bone is neededneeded

If there is If there is insufficient insufficient attached attached gingivagingiva

Indications Contra-indications

The gingivectomytechnique is a methodof excising unwanted gingival tissue

ArmamentariumArmamentarium

Periodontal knives (Kirland and Periodontal knives (Kirland and Orban)Orban)

Bard-Parker blades, no. 15Bard-Parker blades, no. 15 ScissorsScissors CurettesCurettes GauzeGauze Periodontal dressing/packPeriodontal dressing/pack

Kirkland and Orban Kirkland and Orban knifeknife

Orban knife Kirkland knife

Steps in the gingivectomy Steps in the gingivectomy techniquetechnique

Establish local anesthesiaEstablish local anesthesia– regional or local anesthesia. regional or local anesthesia.

1;50,000 epinephrine1;50,000 epinephrine is often is often used to help used to help control bleedingcontrol bleeding

Surgical ProcedureSurgical Procedure

1. Pockets explored and marked with a 1. Pockets explored and marked with a pocket marker. Each pocket is marked pocket marker. Each pocket is marked in several areas to outline its course in several areas to outline its course on each surface.on each surface.

2. Periodontal knives and Blades 15 2. Periodontal knives and Blades 15 are used for incisions:are used for incisions:– Incision should be beveled at ~45 degrees Incision should be beveled at ~45 degrees

to the tooth surface and should re-create to the tooth surface and should re-create the normal festooned pattern of the the normal festooned pattern of the gingiva.gingiva.

(continued…)(continued…)

Surgical ProcedureSurgical Procedure

– Incision is started apical to base of the Incision is started apical to base of the pockets and is directed coronally to a pockets and is directed coronally to a point between the base of the pocket point between the base of the pocket and the crest of the bone.and the crest of the bone.

3. Remove the excised pocket wall3. Remove the excised pocket wall 4. Remove any remaining calculus to 4. Remove any remaining calculus to

leave a smooth and clean root leave a smooth and clean root surfacesurface

5. Cover the area with a periodontal 5. Cover the area with a periodontal dressingdressing

Step 1: determine probing depth

Step 2: incision

Step 3: removal of tissue

Step 4: hemostasis

Step 5: periodontal pack

Patient presentationPatient presentation

““I would like to get I would like to get braces…”braces…”

Radiographic Radiographic examinationexamination

Altered passive eruption?Altered passive eruption?

““Gummy smile”Gummy smile”

““Gummy smile”Gummy smile”

Presence of calculusPresence of calculus

Healing after the Healing after the gingivectomygingivectomy Formation of blood clotFormation of blood clot Replacement of clot by granulation tissueReplacement of clot by granulation tissue Granulation tissue grows coronally forming new Granulation tissue grows coronally forming new

gingival margin and sulcusgingival margin and sulcus After 12 to 24 hours epithelial cells at wound After 12 to 24 hours epithelial cells at wound

margins migrate over granulation tissuemargins migrate over granulation tissue Surface epithelialization is usually complete by Surface epithelialization is usually complete by 5 5

to 14 days. to 14 days. Complete epithelial repair is complete in ~ 1 Complete epithelial repair is complete in ~ 1

monthmonth Complete repair of connective tissue take ~ 7 Complete repair of connective tissue take ~ 7

weeksweeks

Healing after Healing after gingivectomygingivectomy Primary intention: Covering the Primary intention: Covering the

exposed surgical wound area with exposed surgical wound area with a flap by a flap by suturingsuturing..

Secondary intention: Surgical Secondary intention: Surgical area is not sutured and area is not sutured and allowed to heal by surface allowed to heal by surface epithelializationepithelialization

Periodontal Periodontal Dressing/PackDressing/Pack

Periodontal DressingPeriodontal Dressing

Content: Zinc oxide, an oil (for plasticity), Content: Zinc oxide, an oil (for plasticity), a gum (for cohesiveness), and bithionol a gum (for cohesiveness), and bithionol (a fungicide), resin, coconut fatty acids (a fungicide), resin, coconut fatty acids and chlorothymol (a bacteriostatic and chlorothymol (a bacteriostatic agent).agent).

Function: acts as a physical and Function: acts as a physical and protective barrier. No curative properties.protective barrier. No curative properties.

As it sets it becomes retentive As it sets it becomes retentive Should be removed after ~ 7 daysShould be removed after ~ 7 days

2 week post-op2 week post-op

Before

After

Prevention of Prevention of recurrencerecurrence Eliminate local factors: Plaque Eliminate local factors: Plaque

and calculus.and calculus. Periodontal maintenance therapy Periodontal maintenance therapy

and Oral Hygiene instructions. and Oral Hygiene instructions.

Treatment PlanTreatment Plan

Instructions in oral hygiene Instructions in oral hygiene Toothbrushing Toothbrushing

Flossing Flossing

Use of mouthwash Use of mouthwash (Chlorhexidine gluconate)(Chlorhexidine gluconate)

Scaling Scaling GingivectomyGingivectomy Supportive Periodontal TherapySupportive Periodontal Therapy

ReferralReferral

The patient should be referred to a The patient should be referred to a periodontist for treatment periodontist for treatment

Supportive Periodontal Therapy Supportive Periodontal Therapy could be shared by periodontist could be shared by periodontist and general dentist and general dentist

Other methods:Other methods:

Electrosurgery: For minor gingivoplastyElectrosurgery: For minor gingivoplasty Laser gingivectomy: not recommendedLaser gingivectomy: not recommended

All three methods are All three methods are NOT NOT recommendedrecommended

For gross removal of gingival mass, For gross removal of gingival mass, surgicalsurgical gingivectomy is the preferred gingivectomy is the preferred method and is very predictable.method and is very predictable.