Derick Mussen Preventive Healthcare

Soft Tissue Procedures

• Banish Your Bad Breath And Gum Disease

Gingivectomy. Gingivectomy is the removal of diseased or hypertrophied gingiva. Introduced by G.V. Black,31, 3- it was the first periodontal surgical

approach to gain widespread acceptance. Gingivec-tomy is essentially the resection of keratinized gingiva only, and it may be applied to the treatment of suprabony pockets'36 and to fibrous or enlarged gingiva, particularly when they result from diphenyl-hydantoin (Dilantin) therapy37 (see Fig 1-4). However, it is unsuitable for the treatment of infrabony defects.

Technique. The surgical technique consists of establishing bleeding points (Fig. 5-16) at the base of the gingival sulcus with a pocket marker or peri-odontal probe to serve as a guide for the gingival excision. The initial incision (Fig. 5-17) is made to these points in a beveled fashion with firm, continuous strokes from the gingivectomy knife. The in-terproximal tissue is freed by sharp excision and is removed from the site. The resulting ledge of tissue at the buccal and lingual or palatal terminations of the incision (Fig. 5-18) is then smoothed with the

Fig. 5-16. Demarcation of pocket depth before the initial incision of a gingivectomy.

Fig. 5-17. Initial incision for the gingivectomy.

Fig. 5-18. Final gingival contours after removal of the coronal tissue and beveling of the incised area.

knife or a rotary instrument to a margin continuous with the remaining tissue.

After vigorous debridement of the newly accessible tooth surfaces, a surgical dressing is applied for protection and hemostasis; it remains in place for 7 to 10 days. When it is removed, oral hygiene procedures are immediately resumed (Fig. 5-19).

Contraindications. The major contraindication to gingivectomy-gingivoplasty is the absence of attached keratinized tissue. The procedure should be confined to areas of keratinized tissue to prevent leaving gingival margins that consist of alveolar mucosa (which is ill-suited to resisting the trauma of restorative procedures and mastication).

Open Debridement (Modified Widman Procedure). Open debridement or curettage is a surgical procedure designed to gain better access to root surfaces for complete debridement and root planing. The modified Widman approach 38 has been advocated in recent years, because it allows good soft tissue flap control, minimum surgical trauma, and good postoperative integrity without excessive loss of osseous tissue or connective tissue attachment.

Technique. A sulcular or minimal internal bevel incision (Fig. 5-20) is made on the buccal or the lingual surfaces of the mandibular teeth. Next, a scalloped internal bevel incision is made on the palatal surfaces of maxillary teeth. The palatal flap is then thinned and the underlying connective tissue removed. The resulting flaps are reflected minimally yet sufficiently to allow access for complete de-bridement of the root surfaces and degranulation of any osseous lesions in the field. No osseous resection is accomplished, except where necessary for proper flap placement. The flaps are then carefully coapted and sutured to promote healing by primary intention (Fig. 5-21).

Mucosal Repair. Mucosal reparative surgery is used to increase the width of the band of kera-tinized gingiva. It is particularly useful where

Fig. 5-19. Result of the gingivectomy, 6 months after surgery. Note the excellent gingival health and contours.

Fig. 5-18. Final gingival contours after removal of the coronal tissue and beveling of the incised area.

Fig. 5-19. Result of the gingivectomy, 6 months after surgery. Note the excellent gingival health and contours.

Internal bevel incision. A, Ending on the bone, to allow reflection of the flap. B, Flap reflected. The supracrestal connective tissue and epithelium are to be removed. E, Enamel; S, sulcus; P, supracrestal periodontium; R, root.

(Redrawn from Carranza FA fr: Glickman's clinical periodontology, ed 7, Philadelphia, 1990, WB Saunders.)

A, Initial thinning incision on the buccal for open debridement. B, Lingual flap thinned. C, Roots planed to remove subgingival accretions. D, Roots debrided and planed. E and F, Flaps coapted and sutured. G and H, The completed restoration, with a healthy periodontium.

complete-coverage restorations are planned (see Chapter 6 for a more detailed discussion).

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