Periodontal plastic and Esthetic surgery

Mucogingival problems and their management.

Prof dr.Mohamed nassar. (BDS.MS.PH.D.LD.) Former vice president of Tanta university , former Dean Tanta dental faculty.

Lecture outline.
Terminology.\definition. Objective,indication and contraindication. Etiology of Marginal tissue recession. Factors that affect S outcome. Irregularity of teeth. Mucogingival line.

Lecture outline. Surgical techniques

Techniques to increase the width of attached gingiva. (gingival Aug apical to R) (Gingival Aug coronal to R (RC) Technique to deepen vestibule. Technique to remove frenum. Criteria for selection of techniques.

THE EFFECT OF CHRONIC PERIODONTITIS

1-Periodontal pocketing extending below MGJ with to or apical to vestibular depth can be treated with apical positioned flap alone or with FGG 2-Generalized gingival recession can be treated by free gingival graft combined with Cp flap.

MUCOGINGIVAL PROBLEMS CAN ARISE FROM THE EFFECTS OF: 1-Chronic Periodontitis.
2-Frenum pull 3-Gingival recession

Mucogingival problems.These are

1-Pockets extending up to or beyond mucogingival junction. 2-Recession causing denudation of root surfaces. 3-Higj Frenum and muscle atta. 4- Inadequate width of attached gingiva.

The rational of surgical procedures

1-Removal of the disease. 2-The production of periodontal anatomy which allow the effective removal of plaque control to prevent recurrance.it can be treated by apically positioned flap

Objective ,indications and contraindications .

Objectives. 1-Widening the zone of Att gingi 2-coverage of denuded roots. 3- Removal of aberrangt frenum. 4-creation of some Vestibular depth when its lacking. 5-adjanct to pocket elimination.

Indications .
1-Augmentation of the edentulous ridge. 2-prevention of ridge collapse associated with tooth extraction. 3- crown lengthening. Loss of interdental papilla (esthetic ,phonetic problem)

contraindications
CONTRAINDICATIONS TO SURGERY. 1-unsatisfactory plaque control
2-Smokers

THE EFFECTS OF FRENAL PULL

1-Interferes with effective plaque control.
2- Pulls on the wall of the pocket and aggravates the lesions.

Fremu, pull cause diastema

Dissecting frenum pull

FRENECTOMY.(complete

f removal with its attachment to bone while frenetomy is incision , relocate

Its indicated where the attachment of a frenum or muscle attachment is so close to the gingival margin so that it interfere with efficient plaque removal and contribute for persistent gingival inflammation.for correction of diastema.

Technique.
1-anathetizing the area. 2-incise along the upper surface of hemostate.repeat to under surface. 3- Remove triangular resected portion exposre fibrous connection to bone, removing it. 4-close with interrupted suture.

Techniques to increase the width of attached gingiva.(G extention ) 1-free soft tissue autograft. Indications. A-an inadequate zone of att.G. B-abnormal muscle attachment. C-shallow vestibular depth . D-Gingival recession. E-Deep pocket to prevent epi rapid down growth.

Advantage and disadvantages.

1-high degree of predictability with increase of keretinized G. 2-simplicity &ability to treat multiple teeth at same time. Disadvantage. 1-two operational sites.Lack predictabilty for root coverage. 2-discomfort ,compromised BS.

procedure.1-classic and variant techniques

Classic steps. 1- eleminate pockets. 2preparation of recepient site. 3-obtaining the graft from doner site.(partial T masticatory M).AT,Palatal mucosa. Transfer and immoblize .protection of doner site.

Graft Properties .
1-it should be thin enough to allow for fluid diffusion . Too thinshrivel expose bed. Too thick..tissue separation. 2- ideal thickness 11.5mm.injurey to palatal arteries.

Variant techniques.
Four varients techniques. 1-Accordian technique. 2-Strip technique. 3-connective tissue technique. 4- combination of strip and CT.(thick3-4 graft and slice it to two portions.)

Sub-epithelial connective tissue graft for root coverage

Indication: 1-Inadequte doner site for pedicle graft . 2-Isolated wide recessions not usually amenable to free gingival grafting(especially on the
3-Multiple root exposure
maxilla)

Subepith,connctive tissue graft indication continue

4- Recession adjacent to edentolous areas require ridge augementation 5-Multiple root exposure with minimal attached gingiva.

Advantage and disadvantage of sub-epithelial connective tissue graft.

1-advantage: 1-Double blood supply to the graft. 2-Minimal palatal denudation, primary intention healing. 3-one step procedure 4- Excellent color blend 5-Coverage of existing crown margins

Healing of the graft.

1-Plasmotic graft circulation by direct capillaries joining. 2- Functional capillary circulation stage. Epith.(sparse) 3-Organization stage.growth of fibroblasts capillaries network and epithelization (2 intention h)

FULL THICKNESS,THICK EPITHELIAL FLAP

Factors affecting success 1-Incorect choice of site for procedure used ,i.e wrong class Gr 2-The graft may be too thick.If such a graft become vascularized the remaining part stand away from the rest of the tissue. 3-If the graft is too thin it may perforate and necrosis .4-if the underlying blood clot is too thick the graft may be discarded.

Other techniques for widening of zone of at.G

1-periosteal separation or fenestration. 2-vestibular extension operation/(adlan and Mejchar)

THE TREATMENT OF GINGIVAL RECESSION

LOCALIZED GINGIVAL RECESSION.
1- its mostly seen with buccally placed roots associated with teeth with thin buccal bone. 2-commen in lower incisors and upper canine ,premolars and first molar.

LOCALIZED GINGIVAL RECESSION

This may affect single or multiple teeth may be caused by. 1-Underlying local bony dehiscence (s) with associated tooth brushing trauma. 2-Direct gingival trauma from occlusion such as deep over bite.

Localized Gin.Recession
.3-IT can be increased by strong muscle pull
4-It can be managed by surgical or conservative methods.

Defect classification,clinical criteria ,possible construction.by MILLER 1985

Class1
Wide or narrow

Full height papilla Full height papilla Reduced papilla height

Recession
Not to mgj.100%c
Recession at or beyond MJL 100% coverage possible Recession at or beyond MJL.coverage only to papillary level.

Class 11
wide or narrow.

Class 111
May be malposed

Class 1V

Gross Extend beyond flattening or mgj. malposed loss of papil

Not possible to cover

Procedure for Root coverage.indication

1-Reduce root sensitivity . 2- improve esthetics. 3-Mange the defects resulting from root caries and abrasions. 4-manage mucogingival defects which fail to respond to plaqque control.

CONSERVATIVE MANAGEMENT OF GINGIVAL RECESSION

1-Root dentine sensitivity
2-Abrasion/erosion. 3-Root caries.

FREE GINGIVAL GRAFT FOR ROOT COVARAGE (THICK,STRETCHED)

Indication 1-Isolated narrow or wide recession (usually on mandibular teeth).
2- To increase width of attached gingiva.

3-To increase vestibular depth.

FREE GINGIVAL GRAFT

ADVANTAGES: 1-One stage procedure 2-Increase amount of keratinized gingiva. 3-Eliminates frenum attachments. 4-Covers multiple shallow wide defects.

FREE GINGIVAL GRAFT

DISADVANTAGES. 1-Usually poor color blend with adjacent tissue:the thicker
keratinization of palate appears whiter than the buccal gingiva.

2-larger denuded area of the palate which may be painful during

healing.

3-precise suturing technique. 4-Technique-sensitive.

Free gingival graft disadvantage

5-May be two stage procedure if the free gingival graft is placed first then coronally repositioned at later date. 6- Limited success with multiple wide recessions of the maxilla due to inadequate blood supply.

POSSIBLE TECHNIQUE FOR ROOT COVERAGE

1-Pedicle Grafts. .coronally repositioned flap. .laterally repositioned flap. .Double papillary flap. 2-Free Grafts. .Full thickness,thick epith Ct .Connt tissue with double papil. 3-GTR

PEDICLE GRAFT
INDICATION: 1-Isolated narrow-deep or shallow recession on mandi,R 2-Adequte band of keratinized gingiva on neighboring teeth. 3-Adequte vestibular depth 4-Isolated wide-shallow recession on maxillarly or mandibular teeth.

Pedicle graft
ADVANTAGE: 1Good color blend. 2-One stage procedure. 3-Blood supply from base of the flap , periosteum adjacent to denuded area. 4-Not necessity for second surgical site. 5-Minimal post-operative sequela.

Preparation of the bed

PEDICLE GRAFT
DISADVANTAGE: 1-Limited to narrow or shallow isolated recessions. 2-not for multiple recessions. 3-limited success with wide maxillary recession especially on canines .4-Must have adequate dinner source on adjacent teeth.

Healing of graft,

Pedicle graft transfer and sutured

Full coverage

One year after grafting

GUIDED TISSUE REGENERATRION

NON RESORBABLE MEMBRANCES.
1- CLINICAL PROCEDURS USING TWO STAGE GTR WITH PTFE MEMBRANCES.

RESORBABLE MEMBRANCES. 2-CLINICAL PROCEDURE FOR ONE STAGE PROCEDURE WITH RESORBABLE MEMBRANCE.

CLINICAL PROCEDURE WITH ENAMEL MATRIX DERIVATIVE (EMDOGAIN)

1-CLINICAL TRIALS OF ONE STAGE TECHNIQUE. 2- COMBINED PROCEDURES. A-FREE GINDIVAL GRAFT TO INCREAS THE THICKNESS OF KERATINIZED TISSUES.
B-REGENERATIVE TECHNIQUES.

GTR for root coverage

Pouch and Tunnel technique. To minimise incisions and reflection and to provide abundent blood suppy subepithelial CT graft placed into pouches beneath papillary tunneles that allow intimate contact of donner tissue to R BED

Alloderm skin graft

Substitute to free gingival graft.(bihorizon)

Disadvantage.
1-Technically sensitive
2- Complicated suturing.

Key roles in the success of root coverage procedures.

1-Root surface instrumentation. 2-Root surface preparation. 3-Procedure. .Preparation of the recipient area. .preparation of the donner area; .Postoperative care. .Mode of healing.

Factors that affect surgical outcome

1-Irregularity of teeth.The location of Gm,width AG,bone height and thickness are affected by tooth alignment. 2-tooth that are tilted or rotated labially,the labial bony plate is thinner and located apically than the adjacent teeth. 3-Orthodontic T is indicated.

Factors that affect surgical outcome

2-mucogingival line.. Normally \mgl located 3-5 mm apical to to the crest of bone. In PDD and in malposed free disease the bone is located further apically. After subside of inflammation MJL is moved coronally due to contraction of tissue.

Common mistakes in soft tissue grafting

1-Not enough inter-proximal bone and soft tissue height for procedure. 2-Initial horizontal incision made apical to the CEJ 3- Lifting the inter-proximal papilla entirely. 4-Perforations of the flap. 5-Root not planed well.

Common mistakes. (continue)

6-Recpient bed not wide enough to provide collateral blood cir. 7-Connective tissue graft too small. 8-Conntective tissue graft too thick

Commen mistakes continue

9-connective tissue graft not positioned coronally enough to cover the denuded area. 10-overlying flap not positioned coronally enough to cover the denuded area.

Criteria for selection of mucogingival technique.

1-Surgical site free of plaque ,calculus and inflammation. 2-Adequte blood supply to the donner tissue. 3-Anatomy of the recipient ,donner site. 4-Stability of graft to R BED. 5-Atrumatic technique.

THANK YOU