A Biometric Study of the Effects of Gingivectomy*

B Y O. W A L T E R D O N N E N F E L D * * A N D I R V I N G G L I C K M A N * * *

THERE A R E VARIED opinions regarding the changes in the location of

the healed gingival sulcus and the width of the attached gingiva following the
treatment of periodontal disease by gingivectomy. These have been based prin-
cipally upon clinical impressions. In order to evaluate the outcome of gingi-
vectomy objectively, a clinical study was undertaken in humans in which pre-
and postoperative measurements were made of the location of the base of the
healed gingival sulcus and the width of the attached gingiva. These findings
were further compared with those of a similar investigation on the apically
repositioned flap operation. 1

EXPERIMENTAL PROCEDURE

Fifty-four maxillary anterior teeth with periodontal pockets averaging 2.6

mm. with a range of depth of 1.0 mm. to 7.0 mm. were selected for analysis.
These were distributed in groups of six maxillary anterior teeth in nine patients
between the ages of 25 and 46 years of age (Fig. 1). Pockets were excised
by gingivectomy incision and the teeth were scaled and roots smoothed (Fig.
2). The operated areas were packed for one week with Kirkland-Kaiser perio-
dontal pack and repacked for an additional week with Coe-Pac when neces-
sary. After pack removal, the patients were instructed in a modified Charter's
method of toothbrushing with a hard natural bristle brush and a rubber tip
for interdental cleansing.

The following measurements were made prior to gingivectomy, at the time

of operation, and at 1, 2, 4, 8 and 12 week postoperative intervals (Fig. 3):

A. Location of base of gingival sulcus: the distance from the cemento-

enamel junction to the base of the periodontal pocket before the operation,
to the gingivectomy incision at the time of the operation, and to the base of
*From the Department of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts.
**Assistant Professor of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts.
***Professor and Chairman of the Department of Periodontology, Tufts University School of Dental Medicine,
Boston, Massachusetts.

Page 5/447
Page 6/448 DONNENFELD AND G L I C K M A N

Fig. 1. Before operation. Patient with periodontitis. Fig. 2. At time of gingivectomy. Periodontal pockets
Tattoo marks on muco-gingival line. excised. Roots scaled and smoothed.

the healing gingival sulcus during the post-

operative observation periods.

B . W i d t h of the attached gingiva: the

distance from the cemento-enamel junction
to the muco-gingival line minus measure-
ments " A " . F o r purposes of measurement,
the muco-gingival line was marked with tat-
too points.

A l l measurements were made on the m i d -

facial aspects of the teeth with calipers,
Boley gauge, and a William's calibrated
probe. A l l measurements were to the nearest
half millimeter and all mean measurements
were rounded to one tenth of a millimeter.

FINDINGS

a. Distance from the cemento-enamel

junction to the base of the gingival sulcus
(Table 1 ) .

In all patients the base of the periodontal Fig. 3. Measurements employed during experimental
period. "A" is preoperative distance from cemento-
pocket before gingivectomy was apical to enamel junction (CEJ) to base of periodontal pocket
the cemento-enamel junction. The mean and postoperatively to base of healing gingival sulcus.
"AG" is attached gingiva. Its width is computed by
preoperative distance from the cemento- measuring distance from CEJ to muco-gingival line
enamel junction was 1.9 m m . with a range minus measurement "A."
of 0.4 m m . to 4.0 m m . A t time of operation
the gingivectomy incision was located apical After the first and second weeks the base
to the base of the pocket for all patients of the healing gingival sulcus was coronal to
except patients N o . 3 and N o . 7 where it the line of incision on all teeth except i n
was at the level of the base of the pocket. patient N o . 9 where it was located apically.
The mean distance of the gingivectomy The mean distances from the cemento-
incision was 2.1 m m . from the cemento- enamel junction to the base of the newly
enamel junction and was 0.2 m m . apical formed sulcus at the one and two week inter-
to the base of the untreated periodontal vals were 1.7 m m . and 1.6 m m . , respec-
pocket. tively. The latter measurement represented
 GINGIVECTOMY — A BIOMETRIC STUDY Page 7/449

TABLE 1

Distances F r o m the Cemento-enamel J u n c t i o n ( C E J ) to the Base of G i n g i v a l Sulcus

D u r i n g the 12 W e e k E x p e r i m e n t a l P e r i o d

Md
Patient Teeth B* o** 1 2 4 8 12 B-12 0-12

1 6 2.0 2.2 1.7 1.3 1.7 1.5 1.8 0.2 0.4

2 6 1.7 1.8 1.3 1.4 2.2 1.8 1.9 -0.2 -0.1
3 6 2.0 2.0 1.1 1.1 1.4 1.3 1.3 0.7 0.7
4 6 0.8 1.0 0.9 0.8 0.5 0.6 1.0 -0.2 0.0
5 6 2.3 2.9 2.5 2.5 3.4 3.4 3.6 -1.3 -0.7
6 6 3.7 3.8 2.5 2.4 2.6 2.9 2.3 1.4 1.5
7 6 4.0 4.0 3.2 3.4 3.9 3.6 3.6 0.4 0.4
8 6 0.6 1.3 0.8 0.9 1.1 1.5 1.3 -0.7 0.0
9 6 0.4 0.5 0.9 0.7 0.9 1.6 1.5 -1.1 -1.0

Mean 6 1.9 2.1 1.7 1.6 2.0 2.0 2.0 -0.1 +0.1

B * Distance f r o m C E J before operation to base of periodontal pocket.

0** Distance f r o m C E J at time of operation.

TABLE 2

W i d t h of the A t t a c h e d G i n g i v a D u r i n g the 12 W e e k E x p e r i m e n t a l P e r i o d

Md
Patient Teeth B* #** 1 2 4 8 12 B-12 0-12
1 6 3.3 3.1 3.1 3.6 3.0 3.1 3.0 -0.2 0.0
2 6 3.9 3.8 4.4 4.3 4.0 3.7 3.6 -0.3 -0.2
3 6 2.0 1.8 3.1 3.0 2.7 3.2 2.8 0.8 1.0
4 6 4.4 4.2 4.3 4.3 4.5 4.4 4.1 -0.3 -0.1
5 6 3.0 2.4 2.7 2.8 1.9 1.9 1.9 -1.1 -0.5
6 6 5.4 5.0 5.4 5.5 5.3 5.0 4.7 -0.7 -0.3
7 6 1.8 1.8 2.6 2.5 1.9 1.2 1.5 -0.3 -0.3
8 6 5.3 4.6 5.3 4.9 4.8 4.3 4.3 -1.0 -0.3
9 6 1.7 1.6 2.4 2.3 2.2 2.3 2.3 0.6 0.7

Mean 6 3.4 3.1 3.7 3.7 3.4 3.2 3.1 -0.3 -0.0

B * W i d t h o f attached gingiva before gingivectomy.

0** W i d t h o f attached gingiva at time of operation.

a mean coronal shift beyond the gingivec- with a range from 0.2 m m . to 1.4 m m . ; i n
tomy incision of 0.5 m m . with a range of three of the nine patients there was a mean
0.2 m m . to 1.4 m m . A t the fourth postoper- apical shift of the base of the gingival sulcus
ative week and for the balance of the twelve- of 0.6 m m . with a range from 0.2 m m . to
week experimental period, the mean dis- 1.3 m m . ; and i n two patients, no change
tance from the cemento-enamel junction to occurred. W h e n these shifts i n the location
the base of the gingival sulcus remained of the base of the healed gingival sulci were
constant at 2.0 m m . This location was 0.1 scored by the t test, the value was < 1 which
m m . coronal to the line of incision and 0.1 was not statistically significant.
m m . apical to the base of the untreated
pockets ( F i g . 4 ) . Width of the Attached Gingiva (Table 2).
The mean preoperative width of the at-
In four of the nine patients, there was a tached gingiva was 3.4 m m . with a range of
mean coronal shift of the base of the healed 1.7 m m . to 5.4 m m . The width of the
sulcus beyond its untreated level of 0.8 m m . attached gingiva varied as follows during
Page 8/450 DONNENFELD AND GLICKMAN

TABLE 3

Distances F r o m Cemento-enamel Junction

( C E J ) to M u c o - g i n g i v a l L i n e (Tattoo) Before
G i n g i v e c t o m y and A f t e r 12 W e e k s

Number Weeks Md
Patient of Teeth £* 12 0-12

1 6 5.3 4.7 0.6

2 6 5.6 5.5 0.1
3 6 4.0 4.1 -0 1
4 6 5.2 5.1 0.1
5 6 5.2 5.5 -0.3
6 6 9.1 7.0 2.1
7 6 5.8 5.1 0.7
8 6 5.8 5.5 0.3
9 6 1.9 3.8 -1.9

Mean 6 5.3 5.1 0.2

B * P o s i t i o n of T a t t o o before G i n g i v e c t o m y .

value of 1.35 which was statistically insig-

nificant. The fact that the width was reduced
in seven of the nine patients nevertheless
indicated a trend i n that direction. The t
value was reduced by patients N o . 3 and
N o . 9 i n w h o m there was a relatively large
increase i n the width of the attached gingiva.

Fig. 4. Bar graph illustrating changes in location of Tattoo at the Muco-gingival Line (Table
base of the gingival sulcus (EA) following gingivec-
tomy as measured from cemento-enamel junction 3). The distance from the cemento-enamel
(CEJ). At the end of 12 weeks, it is apical (0.1 mm.) junction to the muco-gingival line at the end
to its pretreatment level (B) but coronal (0.1 mm.)
to line of gingivectomy incision (0). of the twelve-week experimental period was
less than its pre-treatment mean measure-
the experimental period: after one week it ment of 5.3 m m . The tattoo marks moved
was reduced by 0.3 m m . to a mean width of from 0.1 m m . to 2.1 m m . toward the
3.1 m m . with a range of 1.6 m m . to 5.0 m m . cemento-enamel junction i n six of the nine
The width increased during the next post- patients and i n three patients, it moved api-
operative week by a mean value of 0.6 m m . cally from 0.1 m m . to 1.9 m m . The mean
which was largely due to granulation tissue distance at the end of the study was 5.1 m m .
at the gingivectomy incision. Beginning with from the cemento-enamel junction which
the second postoperative week the width of represented a coronal shift of 0.2 m m . W h e n
the attached gingiva diminished until the these measurements were scored by the t
twelfth postoperative week when it meas- test, they scored < 1 which was statistically
ured 3.1 m m . This represented a mean loss insignificant.
of 0.3 m m . as compared with its preopera-
Correlation in Shifts of Both the Base of
tive width. In seven patients the loss i n
the Healed Gingival Sulcus and the Muco-
width of the attached gingiva ranged from
gingival Line. The shifts i n the location of
0.3 m m . to 1.1 m m . and i n two patients
the base of the healed gingival sulcus and
there were increases i n width of 0.6 m m .
the muco-gingival line were not statistically
and 0.8 m m . , respectively.
significant i n themselves. Both scored <1
The reduction i n the width of the at- on the basis of the t test. However, when
tached gingiva from its pretreatment meas- these measurements were scored against
urement when scored by the t test yielded a one another for each patient it was found
 GINGIVECTOMY — A BIOMETRIC STUDY Page 9/451

incision was made apical (0.2 m m . ) to the

base of the pocket and at the end of the ex-
perimental period, the base of the healed
gingival sulcus was coronal (0.1 m m . ) to
the line of incision. O u r findings are con-
trary to earlier reports ' » stating that gin-
2 3 4

givectomy contributes to gingival recession.

There was tendency toward reduction i n

the width of the attached gingiva (mean loss
of 0.3 mm.) following gingivectomy which
was not statistically significant nor clinically
notable. It resulted from a combined shift i n
the location of the muco-gingival line to-
ward the cemento-enamel junction and the
shift of the base of the healed gingival sul-
cus toward the apex. These points migrated
toward each other i n all patients. T h e coro-
Fig. 5. Twelve weeks following gingivectomy scatter- nal shift i n the muco-gingival line (0.2 m m . )
gram shows consistent correlation between the move- contributed more to the reduction i n width
ment of the muco-gingival line (tattoo) toward the
cemento-enamel junction (CEJ) and the movement of of the attached gingiva than the apical shift
the base of the healed gingival sulcus toward the apex. of the base of the healed gingival sulcus
(0.1 m m . ) . The shift i n the muco-gingival
line may have resulted from tissue contrac-
tion following the resolution of inflamma-
tion associated with healing.

Comparison of the results obtained i n this

study with those reported by the authors i n 1

a similar biometric study of the apically re-

positioned flap operation are informative
(Fig. 7, 8 ) . W i t h the apically repositioned
flap operation, there was a significant i n -
crease i n the width of the attached gingiva,
Fig. 6. Twelve weeks post-gingivectomy.
but this was accompanied by a greater tend-
ency toward gingival recession than that
that they migrated toward each other and following gingivectomy. W i t h the gingivec-
there was a consistent correlation between tomy, an initial increase i n the width of the
the distances moved by the healed gingival attached gingiva occurred during the first
sulcus and muco-gingival line i n each case two postoperative weeks due to tissue pro-
(Fig. 5 ) . liferation at the line of incision. This i n -
crease was subsequently reduced but the
base of the healed gingival sulcus remained
DISCUSSION
coronal to the line of the gingivectomy
The gingivectomy operation eradicated incision. W i t h the apically repositioned
periodontal pockets and restored normal flap, the width of the attached gingiva re-
gingival sulci ( F i g . 6 ) . After twelve weeks mained greater than its pretreatment width
there was a post-treatment apical shift i n the throughout the experimental period but the
location of the healed gingival sulcus of 0.1 level of the base of the gingival sulcus
mm. which was not clinically discernible or shifted apical to the location established at
statistically significant. The gingivectomy time of operation.
Page 10/452 DONNENFELD AND GLICKMAN

Fig. 8. Comparison of width of attached gingiva (AG)

12 weeks following gingivectomy and 12 weeks follow-
Fig. 7. Changes in distance of the healed gingival ing the apically repositioned flap (ARF) operation.
sulcus from the cemento-enamel junction 12 weeks fol- "B" is width previous to operation and "0" is the
lowing gingivectomy (Ging) as compared with the api- width at time of operation. With the gingivectomy
cally repositioned flap (ARF) operation. "B" is the there is a slight reduction in the 12 week postoperative
pretreatment level. With the gingivectomy there is an width of the attached gingiva (0.3 mm.). With the
0.1 mm. apical shift in the location of the base of the ARF there is a significant increase in the width of the
healed gingival sulcus; with the ARF there is greater attached gingiva (1.02 mm.).
recession as indicated by an apical shift of 0.6 mm.

gingivectomy than with the apically reposi-

CONCLUSIONS
tioned flap. O n the other hand, the apically
The gingivectomy operation eliminates repositioned flap results i n a significant i n -
periodontal pockets without causing signifi- crease i n the width of the attached gingiva
cant clinical or statistical changes i n the l o - whereas with the gingivectomy there is a
cation of the base of the healed gingival slight but statistically insignificant reduction
sulcus or i n the width of the attached gin- in the width of the attached gingiva.
giva. The slight reduction i n the width of
the attached gingiva following gingivectomy REFERENCES
(0.3 m m . ) is caused by a coronal migration
1. Donnenfeld, O. W., Marks, D. and Glickman, L :
of the muco-gingival line and to a lesser ex- Apically Repositioned Flap. J. Periodont., 35:381-387,
tent by an apical shift i n the location of the 1964.
2. Waerhaug, J. : Depth of Incision in Gingivectomy.
base of the healed gingival sulcus. Oral Surg., Oral Med. and Oral Path., 8:707-718, 1955.
3. Ramfjord, S. and Costich, E. R.: Healing after
Simple Gingivectomy. J. Periodont., 34:401-415, 1963.
Comparison with similar measurements 4. Korn, N. H., Schaff er, E. M. and McHugh, R. B. :
following the apically repositioned flap op- An Experimental Assessment of Gingivectomy and Soft
Tissue Curettage in Dogs. J. Periodont., 36:97-101,
eration indicates less recession following 1965.

UNIVERSITY OF PENNSYLVANIA
A Clinical Fellowship i n Oral Pathology, supported by the American Cancer Society is available to
qualified applicants, at the University of Pennsylvania, School of Dental Medicine. A tax-free stipend of
$3,600.00 accompanies the Fellowship for 1 year beginning July 1. The deadline for receipt of all creden-
tials is M a r c h 1. Address all inquiries to: C H A I R M A N , Committee on Traineeships and Fellowships,
University of Pennsylvania, School of Dental Medicine, 4001 Spruce Street, Philadelphia, Pennsylvania
19104.