GINGIVECTOMY: INDICATIONS, CONTR,AINDICATIONS, AND

METHOD

HENRY M. GOLDMAN, D.M.D.

T HE treatment of periodontal disease without regard to diagno&, etiology,

and pathology is apt to result in failure. Therefore, if we are to treat our
cases successfully, we must have a thorough knowledge not only of the physiology
of periodontal structures, but also of the changes seen in the disease of these
tissues. Combined with an understanding of the etiological factors, treatment
is successful.
OBJECTIVES

One of the ultimate aims in periodontal treatment is the elimination of

the pathologically deepened gingival crevice. This may be accomplished by
various methods, one of which is gingivectomy. This may be defined as the
surgical removal of the gingiva to the bottom of the pocket. Ascertainment of
the depth and shape of the pocket and its relationship in position to the alveolar
crest is of primary importance. Some operators believe that in periodontal dis-
ease the bone crest is infected or necrotic and, therefore, should be removed when
a gingivectomy is performed. This theory is not substantiated by histologic evi-
dence, since the bone is never necrotic as it is in osteomyelitis. If the gingivec-
tomy is performed correctly, no bone can be exposed since only the free margin
of the gingiva is removed. Fig. 619 shows the interdenta,l tissue between the
first and second mandibular premolars. Calculus deposits are seen at C, alveolar
bone at B, and the bottom of the pockets at E. The dotted line demonstrates
the extent to which the gingiva should be removed in gingivectomy.
INDICATIONS

If a pocket, is so shaped or situated that it will not disappear when the

gingival tissues shrink after subgingival curettage, gingivectomy may be em-
ployed. It should also be used in cases There clinical reattachment cannot be
obtained, or in cases of gingival hyperplasia where the tissue is not reduced by
curettage and stimulation. Here the operation may be termed gingivoplasty
rather than gingiveetomy. Gingivectomy may also be used in cases where the
interdental gingiva is destroyed and the buccal and lingual gingiva remain
intact.
CONTRAINDICATIONS

Gingivectomy should not be employed in those cases where the crevices are
sha.llow and the gingiva is swollen due to inflammation. Here it is usually not
383
324 Thoma, Smith, BOSCO,Blumenthal, and Goldman

Fig. 619.-Interdental tissue between the first and second mandibular premolars. C, Calculu
I 3, alveolar bone; E, bottom of pockets. (U. S. Army Medical Museum Neg. No. 78386.)
 C%nic of iMassachusetts General Hospital 325

necessary to remove tissue since the gingival margins will regress when the in-
flammation subsides and resolves after subgingival curettage, gingival stimula-
tion, and mouth rehabilitation. Gingivectomy is also contraindicated in those
instances in which the base of the deepened gingival crevice is placed further
apically than the alveolar crest. In such intrabony pockets, an attempt to
produce reattachment can be made. It is necessary that all the epithelium in the
pocket be removed, and the tissue readapted. The blood between the tooth and
bone is allowed to clot, and should be protected by suturing the tissue or cover-
ing with a pack. If the operation is successful, the blood clot organizes into con-
nective tissue, and a layer of cementum is formed on the root of the tooth in
which periodontal fibers are incorporat,ed. This is also true of the bone. The
depth of the crevice will then end at the point of formation of new tissue (con-
nective tissue, cementum, and bone).

METHOD

Before gingivectomy, the teeth should be thoroughly scaled and all the
calculus and local irritations removed. The operation should be performed
under local anesthesia. The field should be prepared aseptically with a solution
of castile soap and sponged with an antiseptic solution. The depth of the pockets,
previously investigated, should be marked with either a sterile indelible pencil
or by drawing a scalpel lightly over the gingivae, producing a slight incision.
The incision is then made in a direction that simulates a normal gingival attach-
ment, that is, apically away from the tooth, as otherwise a shelf will be created
where food can lodge. The cut should be made at the base of the pocket, and the
gingiva from around the tooth removed. This is best done by means of a small
knife, or in some cases, with sharp-pointed scissors. The incisions should be
smooth and clean and the tissue should not be traumatized.
If gingivectomy is to be employed throughout the mouth, the b’uccal in-
cision is made first and the tissue lifted off. The lingual cut is then made, using
the knife at an angle that results in the correct bevel. The lingual gingivae are
then raised. With a small knife that can pass through the interproximal spaces,
the interproximal tissues are severed buccopalatally or buccolingually. The en-
tire tissue is removed. The interproximal tissue then may be curetted, and all
inflammatory granulation tissue removed. No ragged tissue or tabs should re-
main. Some operators used the electrocautery to remove these tabs, of tissue,
and it may also be employed to festoon the gingivae, In many instances it is
helpful in trimming the interproximal tissues.
After the operation, bleeding should be stopped; this is best done by pack-
ing the interproximal spaces with small pieces of cotton saturated with adrenalin
or any hemostatic. preparation. After the bleeding has stopped, a pack should
be pIaced on the wound surface. This pack should be mixed very stir? so that
it is the consistency of putty; it is placed between the teeth and packed over the
gingivae. It should extend from the buccal to the lingual surface, and inter-
proximally below the contact points. It will be sufficiently firm to stay in
place a few days. Upon removal, the mouth is irrigated with an astringent
336 Thoma, Smith, BOSCO,Blumentha,l, and Goldman

solution and washed with an antiseptic. In some instances, a few areas should
again be covered, and a periodontal varnish or paraffin wax may be usd. The
patient is instructed to keep his mouth clean.
A few days later, the mouth should again be cleaned of soft deposits by
spraying. If any calculus is seen, it should be removed. When the gingivae
appear fairly well healed, the teeth should be cleaned and well polished. The
final result should produce healthy, pink, firm gingivae with complete elimina-
tion of the pockets.
As stated previously, the alveolar bone should not be disturbed. Curettage
of the alveolar crest is not only unnecessary but erroneous in most cases. There
is only one type of case where there is sufficient reason for removing alveolar
bone, and this is the caSe where an interproximal crater is formed due to loss
of bone. The buccal and lingual crests form ridges which tend to hold the food
in the crater and cause further inflammation of the tissue. It may be necessary
to remove this bone to obliterate this hollow space. In most instances, however,
the removal of the buccal and lingual gingivae alone is sufficient to eliminate
crater formation.