Gingivectomy

causes and treatment of gingiva enlargement

1. MANAGEMENT OF GINGIVAL ENLARGEMENT AND CROWN LENGTHENING Dr : Enas Elgendy Ass. Prof. of Oral Medicine and Periodontology

2. Gingival Enlargement It is excessive over-growth of the gum tissue surrounding teeth. This growth is usually irregular and may or may not be associated with bleeding. It has several causes and patients should be carefully evaluated to determine the origin of the problem.

3. Causes of Gingival Enlargement Inflammatory Enlargement Acute ( gingival abscess, periodontal abscess) Chronic (plaque induced) Medication Causes Phenytoin ( Dilantin ) occurs in 40-50% pts Calcium Channel Blocker s (occurs rarely) Nifedipine ( Procardia ) Diltiazem ( Cardizem ) Cyclosporine birth control pills. Conditioned Pregnancy Puberty Vitamin C deficiency Plasma cell gingivitis Pyogenic granuloma Mouth- breathing

4. Causes of gingival enlargement Systemic Diseases Leukemia Granulomatous diseases ( sarcoidosis , Wegene ’ s granulomatosis ) Acromegaly Neoplastic Enlargement Benign tumors Malignant tumors False Enlargement Increase size of underlying bone or dental tissue

5. Effects of gingival enlargement Oral hygiene becomes impeded. Interfere with speech, occlusion, and esthetics. Interferes with normal tooth eruption. Can cause tooth migration.

6. After management of the inflammatory component by phase 1 therapy surgical correction can be carried out.

7. GINGIVECTOMY AND GINGIVOPLASTY Gingivectomy : is the excisional removal of gingival tissues for pocket reduction or elimination. Gingivoplasty : is the reshaping of the gingiva to attain a more physiologic contour. Gingivectomy and gingivoplasty are usually performed at the same time. Aim is pocket elimination for root accessibility and establishment of physiologic gingival contours.

8. INDICATIONS - Elimination of suprabony pockets in the presence of adequate zone of keratinized tissue. - Fibrotic gingival enlargements . Figure 1: Different types of periodontal pockets. A, Gingival pocket, There is no destruction of the supporting periodontal tissue. B, Suprabony pocket, the base of the pocket is coronal to the level of underlying bone. Bone loss is horizontal. C, Intrabony pocket, the base of the pocket is apical to the level of adjacent bone. Bone loss is vertical.

9. INDICATIONS - Incomplete passive eruption - Unaesthetic or asymmetrical gingiva . -To facilitate restorative dentistry ( C rown lengthening ). -To establish physiologic gingival contours after acute necrotizing ulcerative gingivitis (ANUG), to correct gingival craters and after flap procedures . -To treat some cases of furcation involvement

10. Contraindications: *Absence of adequate zone of keratinized tissue . *Pockets that extend beyond the mucogingival line. *Treatment of intrabony pockets. *When osseous surgery or inductive techniques are recommended. *Gingival enlargement due to blood diseases (e.g. leukemic gingival enlargement) *Highly inflamed or edematous tissues. *Bad oral hygiene.

11. Advantages:  Predictability.  Ease of pocket elimination.  Good access to tooth surface. Disadvantages:  Healing by secondary intention.  Post operative bleeding.  Loss of keratinized gingiva.  Inability to treat intraosseous defects.

12. Various techniques of GINGIVECTOMY Surgical gingivectomy (external and internal bevel gingivectomy) Gingivectomy by electrosurgery Laser gingivectomy Gingivectomy with chemosurgery

13. Types of Gingivectomy Surgical Electrosurgery Laser Chemosurgery

14. 1- Surgical gingivectomy

15. Instrument uses

16. 1- Surgical gingivectomy   1- Anesthesia : Infiltration into marginal and papillary tissues with lidocaine and 1:100,000 epinephrine (vasoconstriction) provides tissue rigidity to facilitate resection. Anesthetic without epinephrine may be used on patients with hypertension or heart disease. 2- Pocket marking The Crane Kaplan or pocket marking forceps bleeding points marked

17. Pocket marking forceps ( C rane kaplane tweezers) Marking the pocket depths

18. Gingivectomy knives GV/GP using the Kirkland knife 3- The gingivectomy incision : the incision can be made by special gingivectomy knives (Kirkland knives) or blade N15 on the facial and lingual surfaces and areas distal to the terminal tooth in the arch just apical to the bleeding points. The incision should be beveled at approximately 45o degrees to the tooth surface and should re-create the normal festooning pattern of the gingiva.

19. GV/GP using the Orban papilla knife 4- Orban and Buck knives are used for interdental incisions. Bard parker blades no 11 and 12 and scissors are used as auxiliary instruments . Following the beveled incisions, horizontal incisions are made between each interdental space with an Orban or Buck knife or using a no. 12 blade on a conventional scalpel handle in order to separate interdental wedges of tissue .

20. 4- Tissue removal : If the incision has completely separated the pocket wall from the underlying tissues, the pocket wall can be removed easily using a curette or scaler . Remains of fibrous connective tissue and granulation tissue are removed thoroughly with sharp curettes. Any further trimming of the gingiva could be done by fine scissors. Residual calculus on the roots should be scaled off the root and root should be planed leaving a smooth clean surface

21. Periodontal dressing: To protect wound from irritation. To control bleeding To control excess granulation tissue P roduction during initial healing.

22. PROCEDURE FOR GINGIVECTOMY beveled primary incision Interdental incisions Tissue removal removal of granulation tissue &calculus periodontal pack

23. The Incision should be beveled 45 degree to the tooth surface to follow normal contouring of the gingiva

24. Healing after gingivectomy The initial response after gingivectomy is the formation of a protective surface clot. The area under the clot undergoes a short phase of acute inflammation. The clot is then replaced by granulation tissue. Epithelial cells migrate from the edge of the wound beneath the clot. They cover the wound in 7-14 days , and keratinize in 2-3 weeks . The formation of a new epithelial attachment may take as long as 4 weeks.

25. Types of Gingivectomy Surgical Electrosurgery Laser Chemosurgery

26. 2- Electrosurgery Uses high frequency current of 1.5 to 7.5 million cycles per second. Single wire electrodes for incising and excising. Loop electrodes for planing tissues. Electrosurgery - Device and tips

27. Cannot be used in patients with poorly shielded cardiac pacemaker . Causes unpleasant odor . If it touches the bone irreparable damage may result. Heat generated by this may cause tissue damage. When the electrode touches the root, areas of cementum burn are produced. Disadvantages Advantages Permits adequate contouring of the tissues and controls hemorrhage.

28. Types of Gingivectomy Surgical Electrosurgery Laser Chemosurgery

29. Laser Gingivectomy Used lasers are carbon dioxide and Nd:YAG lasers. They are used for excision of gingival over growth oral surgery requires precautionary measures to avoid reflecting the beam on instrument surface,

30. Gingivectomy by Chemosurgery Disadvantage Their depth of action cannot be controlled Gingival remodeling is not possible Healing is delayed

31. Crown lengthening is a procedure performed to increase the clinical crown Indication for crown lengthening To increase the clinical crown for restorative treatment. In cases of altered passive eruption (tooth eruption consists of an active and a passive phase. Active eruption is the movement of the teeth in the direction of the occlusal plane, whereas passive eruption is related to the exposure of the teeth by apical migration of the gingiva). For esthetic recontouring of the gingiva in cases of excessive gingival display passive eruption is a normal condition CROWN LENGTHENING

32. CROWN LENGTHENING Procedures for crown lengthening Crown lengthening can be performed by either extension apically Or extension coronally by orthodontic extrusion . in all situations the crown root ratio has to be considered.

33. Factors that determine the surgical procedure for CROWN LENGTHENING Biologic width and level of interproximal bone Width of keratinized gingiva Gingival biotype

34. 1- Biologic Width It is the dimension of space occupied by JE and CT attachment above the alveolar bone. It is recommended that there should be at least 2 mm between the restoration margin and the bone crest to allow adequate biologic width.

35. Biologic width Extension of restorations margin too far subgingivally (2 mm or less from the alveolar bone) will impinge on the attachment apparatus leading to: 1- Gingival inflammation, 2- Bone loss 3- Pocket formation

36. 2- Gingival biotype Direct measurement: Using a periodontal probe Thick B.>1.5mm>Thin B . More prone to additional recession following crown lengthening surgery .

37. CROWN LENGTHENING Surgical procedures for crown lengthening Gingivectomy: this procedure is applied when Ostectomy is not required and the level of the alveolar bone crest allows for the biologic width to be established. Cases of delayed passive eruption & gingival enlargement. Thick gingival biotype Enough zone of keratinized gingiva Apical repositioned flap in cases of Insufficient zone of keratinized gingival. Osseous recontouring and establishment of the biologic width. Thin gingival biotype .

38. CROWN LENGTHENING Procedures for crown lengthening

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