There are two main options for the gingivectomy procedure, standard and surgical flap. The standard technique is faster and easier, but is best suited for small areas, as the raw/beveled edge of gingiva will need to heal by secondary intention. Furthermore, this technique causes increased loss of keratinized tissue, increased patient discomfort, and increased bleeding compared to the surgical flap technique. When using the standard surgical technique, post-surgical homecare must be delayed to allow for healing, whereas homecare can be instituted sooner with the surgical flap technique.
In cases which require large areas to be treated, or if minimal attached gingiva will remain, the surgical flap technique should be utilized. Also, if the entire attached gingiva is affected (as is typical with the hereditary form), the flap technique allows proper thinning/beveling of the resultant tissue and gives a superior result. Finally, the flap technique should be used in cases where osseous surgery will or may be necessary.
Procedure for Standard Gingivectomy
1. Measure the depth of the pocket in several areas on each tooth and note the buccal surface of the gingiva at the base of the pocket. Then, mark a bleeding point 3 mm coronal to the base of the pocket. This can be done with a standard periodontal probe and needle, but is more accurate and efficient if a periodontal pocket marker is used. The 3 mm allows for 1 mm of gingival recession following surgery “die back”, and 2 mm of physiological pocket depth. When accomplished, the contour of the defect will be outlined.
2. The gingivectomy incision(s) are made. These can be performed with a Kirkland or Orban knife, or with a #11 or #15 scalpel blade used on a scalpel handle. The incision can be continuous and thus connecting the teeth, or discontinuous and around each tooth. The incision is started apical to the mark, and carried coronally at a 45-degree bevel to just below the bleeding point line, making sure that the incision starts at least 2 mm coronal to the MJL. Proper beveling restores an anatomically natural contour, speeds recovery, and avoids a blunt gingival margin which would promote plaque accumulation.
3. Remove the excised gingiva with a sharp curette and clean the exposed root surfaces and granulation tissue with a combination of ultrasonic and hand scaling.
4. If indicated, gingivoplasty can be performed to remove any uneven areas and to accomplish final contouring of the gingiva. Knives, blades, lasers, and cautery can be used for this technique, but this author prefers coarse tapered diamond or 12-fluted finishing burs. When shaping with the diamond bur, follow the underlying bony contours.
5. Gingival bleeding (perhaps significant) can be expected. Bleeding generally stops on its own, but several minutes of direct pressure with moistened gauze may speed hemostasis. Electrocautery or hemostatic solutions can be used if necessary.
6. Reevaluate the surgical site for smoothness.
Periodontal Flap Method
The flap technique for treating gingival enlargement is very similar to the envelope flaps utilized for periodontal flap surgery.
1. Measure the depth of the pocket/over-growth in several areas on each tooth and mark the buccal surface of the gingiva at the base of the pocket (as above). This can be done with a standard periodontal probe and needle, but is more accurate and efficient if a periodontal pocket marker is used. When accomplished, the contour of the defect will be outlined. Experienced surgeons may skip this step in areas where the physiologic attachment level is well known.
2. The initial internal bevel incision is made a minimum of 3 mm above the muco-gingival margin with a #15 blade. This incision should be scalloped and should re-create the interdental papilla.
3. Next, the scalpel blade is used to thin the gingiva by removing the interior aspect of the tissue. This will return the gingiva to a normal physiologic width. Subsequently, the interdental areas are cut with a blade or knife and the excess gingiva is removed.
4. The soft tissue tabs are trimmed with LaGrange scissors and the roots scaled and planed.
5. The flap is replaced, and if necessary trimmed to fit the tooth/bone interface correctly.
6. Interdental sutures are used to close the flaps.