Gingivectomy

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Gingivectomy
MeSH D005890

Gingivectomy is a dental procedure in which a dentist or oral surgeon cuts away part of the gums in the mouth (the gingiva ). [1]

Contents

It is the oldest surgical approach in periodontal therapy [2] and is usually done for improvement of aesthetics or prognosis of teeth.

By removing the pocket wall, gingivectomy provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots, creating a favourable environment for gingival healing and restoration of a physiologic gingival contour. The procedure may also be carried out so that access to sub-gingival caries or crown margins is allowed. [2] A common aesthetic reason for gingivectomy is a gummy smile due to gingival overgrowth. [3]

Indications

Elimination of suprabony fibrous and firm pockets

Gingivectomy is the primary treatment method available in reducing the pocket depths of patients with periodontitis and suprabony pockets. [4] [5] In a retrospective comparison between different treatment approach to periodontitis management based on the initial and final gingival health, conventional gingivectomy was proven to be more successful in reducing pocket depths and inflammation compared to non-surgical treatments in pockets measured 3mm or more. [6] Removal of suprabony deep pockets will allow better visibility and access for the removal of calculus. As a result, this provides a suitable environment for the healing of the gingiva and the physiological contour of the gingiva to be restored. [5]

Elimination of gingival enlargement

In cases of gingival enlargement induced by drugs, surgical treatment through a gingivectomy proved to be effective with most patients showing no clinical sign of recurrence after one year. [7] Even though it is the most frequent method of treatment, it is only indicated when overgrowth is severe. [8]

Another cause of gingival enlargement would be a hereditary condition known as gingival fibromatosis. The extensive overgrowth of gingival tissue is usually treated with a gingivectomy, as it produces good aesthetic results. [9] However, recurrence in these cases are unpredictable. [9] This means that those affected face the possibility of undergoing repeated procedures. [9]

Increase clinical crown height

Sub-gingival margins

A gingivectomy can also be done to increase the clinical crown height of teeth. This is suitable in treatment planning for teeth with inadequate tissue for retention of prosthetic restorations as a result of subgingival carious lesions or coronal fractures. [10] Surgical treatment resets the margin while maintaining the biological width and clinical attachment. [10]

Gummy smiles

Up to 3mm of gingival display when smiling is described to be cosmetically acceptable. Gummy smiles are often used to describe smiles where there is more than 3mm of gingival tissue seen clinically and is usually deemed unaesthetic to the individual. [11] Similar to subgingival crevices margins, gingivectomy to increase the crown height can be performed [11] to provide better aesthetics and normal gingival architecture. [5]

Contraindications

Need for bone surgery

When bottom of the pocket is apical to the Mucogingival junction

Aesthetic considerations, particularly in anterior region of Maxilla

Dental/gingival morphologic characteristics and peri-oral variables influence patient's smile frame. They are essential in achieving a predictable successful rehabilitation of patient's smile. [12]

In males and females, the mean vertical height of the maxillary central incisors averages 10.6mm and 9.8mm respectively. [13] With the lip line at rest, the mean maxillary incisors display is 1.91mm for men and 3.40mm for women (nearly double the amount). [13] More recent studies have been done to confirm the statistically significant sexual dimorphism relative to the height of visible maxillary incisor crown at rest. [14] The data from a study also clearly indicates that higher smile lines are more common among female, and lower smile patterns among male patients. [14] A high smile line displays the entire crown of the tooth and an abundant amount of gingiva. Thus, this procedure can be viewed subjectively by some people as some degree of gingival display may be aesthetically pleasing and is considered youthful, and vice versa.

Besides that, the harmony of the gingival outline between anterior and posterior segments may be affected. [12] Some people are more prone to expose the maxillary teeth from second premolar of one side to another side of second premolar while smiling. [15] Hence, there have been discussions in some cases whereby all teeth between the first molars are included in the procedure, especially in surgical crown lengthening, to achieve an aesthetically pleasing gingival architecture blending in harmoniously the gingival contours of the maxillary anterior and posterior teeth. [12] Apart from that, “black triangles” are likely to develop in areas where there is labial or interproximal soft tissue recession. This leads to desired outcome. [12] [16]

Techniques and post-operative management/healing

Gingivectomy can be performed by various techniques. [1]

Surgical gingivectomy

To reduce post-operative pain for the patient, the surgery should be as atraumatic as the surgeon can make it. If the procedure has been carried out carefully, the patient's post-operative pain is minimised. Pain may be experienced initially following the procedure, but this should subside within a few days and can be appropriately controlled with drugs to alleviate the pain. The patient should also be advised to avoid using the area where the surgery was performed when chewing during the initial healing stage. Adequate plaque control is important in ensuring long-term results from the procedure, and if post-operative infection control levels are maintained then the patient should be able to keep a healthy periodontium. However, the outcome of the procedure may be influenced by other general factors such as the systemic status of the patient. If patients do not maintain the appropriate oral hygiene levels and post-operative care, then it is inevitable that the disease will return. Patients may struggle with self-performed oral hygiene initially after the procedure, due to pain and discomfort, so regular visits for professional tooth cleaning are advised. Immediately after the surgery, patients are recommended to rinse with an appropriate anti-plaque agent. After the sutures are removed, the area should be irrigated and the teeth should be polished. If the area is ready for mechanical tooth brushing to begin again, gentle brushing is demonstrated to the patient using a toothbrush that has been softened in hot water. In the early stages after the procedure, the use of interdental brushes is strongly advised against due to the potential damage to interdental tissues in the operated area, toothpicks are recommended as an alternative. The patient is asked to visit every two weeks for monitoring of their plaque levels. The time between visits will gradually increase if the patients’ plaque control is up to standard. [17]

Gingivectomy by electrosurgery

Electrosurgery is defined as the intentional passage of high-frequency waveforms or currents, through the tissues of the body to achieve a controllable surgical effect. [18] It has been used in dentistry for more than 60 years. [19]

Electrosurgery may be used where a blood-free environment is required, providing that there is no bone coming into contact with the instrument and good oral hygiene is maintained. [20] The technique is not widely used due to multiple factors including cost and lack of information available on the topic. [19]

It is essential to have the presence of a circuit in an electrosurgical unit, allowing current to flow. By changing the mode of activation of this current, electrosurgery may be used for the cutting or coagulation of soft tissues. The basic types of electrosurgical techniques are coagulation, desiccation, fulguration and electrosection (cutting). The majority of clinical operations are done by electrosection. [21]

There are two main types of electrosurgical units; monopolar and bipolar. [22] [23]

In monopolar units a separate electrode is needed, usually in the form of an indifferent plate behind the patient's back. The current begins in the electrosurgical unit and flows to the oral site through a wire and then to the secondary electrode. Heat is produced on contact with the oral tissues and cutting results. Bipolar devices have two electrodes on their cutting tip and the current travels from one to the other, which removes the need for an indifferent plate. Bipolar devices make a wider cut. [19]

The results of studies which have looked at healing of electrosurgical wounds compared to scalpel wounds vary widely but it has been found that electrosurgerical equipment minimises bleeding and most patients experience very little post-operative pain after the procedure. There may be more damage to adjacent tissues, slower wound healing and more inflammatory response than the scalpel technique. [19] [24]

Laser gingivectomy

Laser (Light Amplification by Stimulated emission of Radiation).

The Laser types include:

It has been suggested that lasers can give a substantial reduction in bacteria such as Actinobacillus actinomycetemcomitans (Aa) which will reduce inflammation and facilitate the healing process. [25] [26] Laser treatment seems to also have good patient acceptance as patients report minimal pain. Nd:YAG lasers used for curettage of pocket epithelium cause little or no damage to the underlying tissues. [27]

Periodontal health and reattachment of gingival tissues to previously infected root surfaces is the goal of periodontal therapy and this is typically achieved through conventional treatment by scaling, root surface instrumentation and ultrasonic instrumentation. [28] Conventional treatment however does not completely remove plaque and calculus and a laser has been suggested as an effective tool for periodontal treatment because: [29]

It has been suggested that laser treatment results in minimal or no post-operative swelling, bleeding, scar tissue formation or pain. [30]

Regarding wound healing animal studies have shown better response in rat skin after Nd:YAG laser application than following scalpel incisions but this is only valid when energy and frequency parameters were low and higher levels of energy lead to scar formation and delayed wound healing. [31] [32]

The clinical use of a laser for gingivectomy involves repeated lasing and wiping away tissue remnants with moist gauze and this results in a bloodless operating field allowing better visibility and greater ease for the operator. Apart from ablating and coagulating the laser also sterilizes the tissues and eliminates the need for a post-surgical dressing. [33] One study found that in patients with drug induced gingival overgrowth recurrence was minimal or eliminated when comparing laser gingivectomy to scalpel gingivectomy. [34]

See also

Related Research Articles

<span class="mw-page-title-main">Periodontal disease</span> Medical condition

Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cause of tooth loss for adults worldwide. In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Bad breath may also occur.

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

<span class="mw-page-title-main">Crown lengthening</span> Dental procedure

Crown lengthening is a surgical procedure performed by a dentist, or more frequently a periodontist, where more tooth is exposed by removing some of the gingival margin (gum) and supporting bone. Crown lengthening can also be achieved orthodontically by extruding the tooth.

<span class="mw-page-title-main">Gingival and periodontal pocket</span>

Gingival and periodontal pockets are dental terms indicating the presence of an abnormal depth of the gingival sulcus near the point at which the gingival tissue contacts the tooth.

<span class="mw-page-title-main">Scaling and root planing</span> Dental procedure

Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus and then smoothing, or planing, of the (exposed) surfaces of the roots, removing cementum or dentine that is impregnated with calculus, toxins, or microorganisms, the agents that cause inflammation. It is a part of non-surgical periodontal therapy. This helps to establish a periodontium that is in remission of periodontal disease. Periodontal scalers and periodontal curettes are some of the tools involved.

<span class="mw-page-title-main">Gingival enlargement</span> Human disease

Gingival enlargement is an increase in the size of the gingiva (gums). It is a common feature of gingival disease. Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medications. The treatment is based on the cause. A closely related term is epulis, denoting a localized tumor on the gingiva.

<span class="mw-page-title-main">Subepithelial connective tissue graft</span>

In dentistry, the subepithelial connective tissue graft is an oral and maxillofacial surgical procedure first described by Alan Edel in 1974. Currently, it is generally used to obtain root coverage following gingival recession, which was a later development by Burt Langer in the early 1980s.

A gum lift is a cosmetic dental procedure that raises and sculpts the gum line. This procedure involves reshaping the tissue and/or underlying bones to create the appearance of longer or symmetrical teeth, thereby making the smile more aesthetically pleasing. This procedure is typically done to reduce excessively gummy smiles or to balance out an asymmetrical gum line. The procedure, also known as crown-lengthening, has historically been used to treat gum disease. It is only within the past three to five years that dentists have commonly used this procedure for aesthetic purposes. The practice of cosmetic gum lifts was first developed in the late 1980s, but there were few oral surgeons and dental practitioners available to perform the procedures. Gum lifts can also include bone shaping to reduce the prominence of the upper jaw and even out the tooth and gum ratio. This method provides permanent results, while simple gum contouring may result in relapse or regrowth of the gingiva.

Laser-assisted new attachment procedure (LANAP) is a surgical therapy for the treatment of periodontitis, intended to work through regeneration rather than resection. This therapy and the laser used to perform it have been in use since 1994. It was developed by Robert H. Gregg II and Delwin McCarthy.

Guided bone regeneration (GBR) and guided tissue regeneration (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival tissue at sites with insufficient volumes or dimensions of bone or gingiva for proper function, esthetics or prosthetic restoration. Guided bone regeneration typically refers to ridge augmentation or bone regenerative procedures; guided tissue regeneration typically refers to regeneration of periodontal attachment.

Chronic periodontitis is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by the accumulation of profuse amounts of dental plaque. Periodontitis initially begins as gingivitis and can progress onto chronic and subsequent aggressive periodontitis according to the 1999 classification.

Aggressive periodontitis describes a type of periodontal disease and includes two of the seven classifications of periodontitis as defined by the 1999 classification system:

  1. Localized aggressive periodontitis (LAP)
  2. Generalized aggressive periodontitis (GAP)
<span class="mw-page-title-main">Peri-implantitis</span> Inflammatory disease

Peri-implantitis is a destructive inflammatory process affecting the soft and hard tissues surrounding dental implants. The soft tissues become inflamed whereas the alveolar bone, which surrounds the implant for the purposes of retention, is lost over time.

Gingivoplasty is the process by which the gingiva are reshaped to correct deformities. Gingivoplasty is similar to gingivectomy but with a different objective. This is a procedure performed to eliminate periodontal pockets along with the reshaping as part of the technique. This procedure is followed to create physiological gingival contours with the sole purpose of recontouring the gingiva in the absence of the pockets.

Hereditary gingival fibromatosis (HGF), also known as idiopathic gingival hyperplasia, is a rare condition of gingival overgrowth. HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva. It can cover teeth in various degrees, and can lead to aesthetic disfigurement. Fibrous enlargement is most common in areas of maxillary and mandibular tissues of both arches in the mouth. Phenotype and genotype frequency of HGF is 1:175,000 where males and females are equally affected but the cause is not entirely known. It mainly exists as an isolated abnormality but can also be associated with a multi-system syndrome.

Laser gingivectomy is a dental procedure that recontours or scalpels the gingival tissue to improve long term dental health or aesthetics. Compared to conventional scalpel surgery, soft-tissue dental lasers, such as Laser diode, Nd:YAG laser, Er:YAG laser, Er,Cr:YSGG laser, and CO2 lasers, can perform this procedure, offering a precise, stable, bloodless, often less painful, and accelerated healing experience. However, the Laser diode gained more popularity due to its versatility, less interaction with hard tissue, ease of use, and the less expensive set up.

<span class="mw-page-title-main">Gingival grafting</span>

Gingival grafting, also called gum grafting or periodontal plastic surgery, is a generic term for the performance of any of a number of periodontal surgical procedures in which the gum tissue is grafted. The aim may be to cover exposed root surfaces or merely to augment the band of keratinized tissue.

Periodontal surgery is a form of dental surgery that prevents or corrects anatomical, traumatic, developmental, or plaque-induced defects in the bone, gingiva, or alveolar mucosa. The objectives of this surgery include accessibility of instruments to root surface, elimination of inflammation, creation of an oral environment for plaque control, periodontal diseases control, oral hygiene maintenance, maintain proper embrasure space, address gingiva-alveolar mucosa problems, and esthetic improvement. The surgical procedures include crown lengthening, frenectomy, and mucogingival flap surgery.

Drug-induced gingival enlargement (DIGE), also referred to as drug-induced gingival hyperplasia (DIGH) or drug-induced gingival overgrowth (DIGO), is a side effect of many systemic medications for which the Gingervae are not the target receptor. It is normally resultant of medications including immunoregulators, calcium channel blockers and anticonvulsants. When allowed to progress assisted by routinely poor oral hygiene, DIGE can lead to pain and disfigurement, however there are great variations in its presentation and severity dependent on the case. It is suggested that enlargement is aided by genetic predispositions, tending to occur more frequently in the papillae of the anterior Gingivae in younger age groups.

References

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  2. 1 2 Zafiropoulos GG, Flores-de-Jacoby L, Tsalikis L, Zimmermann A (1991). "[Gingivectomy]". Deutsche Zahn-, Mund-, und Kieferheilkunde mit Zentralblatt. 79 (7): 571–81. PMID   1756220.
  3. ↑ "Gummy Smile Correction Using Botulinum Toxin With Respective Gingival Surgery". www.unboundmedicine.com. Retrieved 2018-11-06.
  4. ↑ Newman MG, Takei H, Klokkevold PR, Carranza FA (2018). Newman and Carranza's clinical periodontology (Thirteenth ed.). Philadelphia, PA: Elsevier - Health Sciences Division. p. 615. ISBN   978-0-323-53323-2. OCLC   1043758752.
  5. 1 2 3 Kohale BR, Agrawal AA, Raut CP (2018). "Effect of low-level laser therapy on wound healing and patients' response after scalpel gingivectomy: A randomized clinical split-mouth study". Journal of Indian Society of Periodontology. 22 (5): 419–426. doi: 10.4103/jisp.jisp_239_18 . PMC   6128133 . PMID   30210191.
  6. ↑ Waite IM (August 1976). "A comparison between conventional gingivectomy and a non-surgical regime in the treatment of periodontitis". Journal of Clinical Periodontology. 3 (3): 173–85. doi:10.1111/j.1600-051x.1976.tb01865.x. PMID   787013.
  7. ↑ Keglevich T, Benedek E, Gera I (December 1999). "[Clinical experience with the treatment of gingival hyperplasia induced by calcium channel blocking agents]". Fogorvosi Szemle. 92 (12): 363–72. PMID   10641419.
  8. ↑ Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA (June 2006). "The management of drug-induced gingival overgrowth". Journal of Clinical Periodontology. 33 (6): 434–9. doi:10.1111/j.1600-051x.2006.00930.x. PMID   16677333.
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  13. 1 2 Vig, Robert G.; Brundo, Gerald C. (1978-05-01). "The kinetics of anterior tooth display". The Journal of Prosthetic Dentistry. 39 (5): 502–504. doi:10.1016/S0022-3913(78)80179-6. ISSN   0022-3913. PMID   349139.
  14. 1 2 Miron, Hagai; Calderon, Shlomo; Allon, Dror (2012-01-01). "Upper lip changes and gingival exposure on smiling: Vertical dimension analysis". American Journal of Orthodontics and Dentofacial Orthopedics. 141 (1): 87–93. doi:10.1016/j.ajodo.2011.07.017. ISSN   0889-5406. PMID   22196189.
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  19. 1 2 3 4 Bashetty K, Nadig G, Kapoor S (October 2009). "Electrosurgery in aesthetic and restorative dentistry: A literature review and case reports". Journal of Conservative Dentistry. 12 (4): 139–44. doi: 10.4103/0972-0707.58332 . PMC   2879725 . PMID   20543922.
  20. ↑ Waite IM (1975). "The present status of the gingivectomy procedure". Journal of Clinical Periodontology. 2 (4): 241–9. doi:10.1111/j.1600-051X.1975.tb01748.x. PMID   1061722.
  21. ↑ Babaji P, Singh V, Chawrasia V, Jawale MR (2014). "Electro surgery in dentistry: Report of cases". Journal of Pediatric Dentistry. 2 (1): 20. doi: 10.4103/2321-6646.130379 . S2CID   72435121.
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  24. ↑ Manivannan N, Ahathya RS, Rajaram PC (July 2013). "Scalpel versus electrosurgery: Comparison of gingival perfusion status using ultrasound Doppler flowmetry". Journal of Pharmacy & Bioallied Sciences. 5 (Suppl 2): S154–9. doi: 10.4103/0975-7406.114317 . PMC   3740665 . PMID   23956596.
  25. ↑ Moritz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O, Wernisch J, Sperr W (1998). "Treatment of periodontal pockets with a diode laser". Lasers in Surgery and Medicine. 22 (5): 302–11. doi:10.1002/(SICI)1096-9101(1998)22:5<302::AID-LSM7>3.0.CO;2-T. PMID   9671997. S2CID   5655059.
  26. ↑ Moritz A, Gutknecht N, Doertbudak O, Goharkhay K, Schoop U, Schauer P, Sperr W (February 1997). "Bacterial reduction in periodontal pockets through irradiation with a diode laser: a pilot study". Journal of Clinical Laser Medicine & Surgery. 15 (1): 33–7. doi:10.1089/clm.1997.15.33. PMID   9467340.
  27. ↑ Gold SI, Vilardi MA (July 1994). "Pulsed laser beam effects on gingiva". Journal of Clinical Periodontology. 21 (6): 391–6. doi:10.1111/j.1600-051X.1994.tb00735.x. PMID   8089240.
  28. ↑ O'Leary TJ (February 1986). "The impact of research on scaling and root planing". Journal of Periodontology. 57 (2): 69–75. doi:10.1902/jop.1986.57.2.69. PMID   3514839.
  29. ↑ Kerns DG, Scheidt MJ, Pashley DH, Horner JA, Strong SL, Van Dyke TE (July 1991). "Dentinal tubule occlusion and root hypersensitivity". Journal of Periodontology. 62 (7): 421–8. doi:10.1902/jop.1991.62.7.421. PMID   1920008.
  30. ↑ Romanos GE (2012-12-01). "The state of the science of lasers in dentistry". Journal of Dental Hygiene. 86 (1): 9–10. PMID   22309921.
  31. ↑ Romanos GE, Pelekanos S, Strub JR (1995). "Effects of Nd:YAG laser on wound healing processes: clinical and immunohistochemical findings in rat skin". Lasers in Surgery and Medicine. 16 (4): 368–79. doi:10.1002/lsm.1900160408. PMID   7651058. S2CID   40735645.
  32. ↑ Romanos GE, Pelekanos S, Strub JR (February 1995). "A comparative histological study of wound healing following Nd:YAG laser with different energy parameters and conventional surgical incision in rat skin". Journal of Clinical Laser Medicine & Surgery. 13 (1): 11–6. doi:10.1089/clm.1995.13.11. PMID   10150568.
  33. ↑ Elavarasu S, Naveen D, Thangavelu A (August 2012). "Lasers in periodontics". Journal of Pharmacy & Bioallied Sciences. 4 (Suppl 2): S260–3. doi: 10.4103/0975-7406.100245 . PMC   3467892 . PMID   23066266.
  34. ↑ Mavrogiannis M, Ellis JS, Seymour RA, Thomason JM (September 2006). "The efficacy of three different surgical techniques in the management of drug-induced gingival overgrowth". Journal of Clinical Periodontology. 33 (9): 677–82. doi:10.1111/j.1600-051X.2006.00968.x. PMID   16856895.
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