MUCOGINGIVAL SURGERIES

DEFINITIONS DEVELOPMENT OBJECTIVES & THERAPEUTIC END POINTS OF SUCCESS

SURGICAL TECHNIQUES
CRITERIA FOR SELECTION OF TECHNIQUES

CONCLUSION

INTRODUCED in 1950s

FRIEDMAN 1957 SURGERY DESIGNED TO PRESERVE THE ATTACHED GINGIVA, TO REMOVE FRENA OR MUSCLE ATTACHMENT AND TO INCREASE THE DEPTH OF THE VESTIBULE.

MILLER 1988
TO CORRECT OR ELIMINATE ANATOMIC, DEVELOPMENTAL OR TRAUMATIC DEFORMITIES OF GINGIVA OR ALVEOLAR MUCOSA

ORBAN (1948) - STIPPLING HALL(1980) MARGIN TO MUCOGINGIVAL LINE PROBING

KERATINIZED GINGIVA VS. ATTACHED GINGIVA

DEFINITIONS
GLOSSARY OF PERIODONTAL TERMS (AAP-1992)
PERIODONTAL SURGICAL PROCEDURES DESIGNED TO CORRECT DEFECTS IN THE MORPHOLOGY, POSITION AND/ OR AMOUNT OF GINGIVA , SURROUNDING THE TEETH.

CARRANZA -1996 (8th Ed) PLASTIC SURGICAL PROCEDURES FOR THE CORRECTION OF GINGIVA - MUCOUS MEMBRANE RELATIONSHIPS THAT COMPLICATE PERIODONTAL DISEASE AND MAY INTERFERE WITH THE SUCCESS OF PERIODONTAL TREATMENT.

DEVELOPMENT OF MUCOGINGIVAL PROBLEMS

ERUPTION PATTERNS
TEETH IN LABIOVERSION ROTATED TEETH

THICKNESS OF PERIODONTIUM
TYPE-I NORMAL OR IDEAL DIMENSION OF KERATINIZED TISSUE NORMAL OR IDEAL LABIOLINGUAL WIDTHOF ALVEOLAR PROCESSES 3-5 mm WIDTH

TYPE II

THINNER KERATINIZED TISSUE NORMAL LABIOLINGUAL WIDTH OF ALVEOLAR PROCESS 2 mm KERATINIZED TISSUE

TYPE III

NORMAL OR IDEAL DIMENSION OF KERATINIZED TISSUE THIN LABIOLINGAUL WIDTH OF ALVEOLAR PROCESS ATTACNMENT LOSS DURING ORTHODONTIC TREATMENT

TYPE IV THIN KERATINIZED TISSUE & THIN LABIOLINGUAL DIMENSIONOF ALVEOLAR PROCESS AT RISK FOR MUCOGINGIVAL PROBLEMS

PLAQUE INDUCED INFLAMMATION TRAUMA

HALL 1984
1) TEETH THAT ERUPT IN PROMINENCE INADEQUATE ATTACHED GINGIVA GINGIVAL RECESSION 2) DO NOT BRING BONE AS THEY ERUPT OFF BASAL BONE 3) INADEQUATE ATTACHED GINGIVA & THIN ALVEOLAR BONE PREDISPOSES TO RECESSION NO RECESSION IN THE ABSENCE OF DISEASE

SIGNIFICANCE OF ATTACHED GINGIVA

WAERHUG 1978 MILLER PD JR. 1985

a)

DENTOGINGIVAL FIBRE COMPLEX AS A BARRIER TO INCREASED APICAL FORMATION OF PLAQUE

b)

FIBROBLASTS IN ALVEOLAR MUCOSA

KRAMER 1980
BIOLOGIC RATIONALE FOR MUCOGINGIVAL SURGERIES

TOPOGRAPHY OF PERIODONTIUM GINGIVAL FIBRE CONNECTION TO TOOTH MOST RELIABLE & NATURALLY OCCURING DEFENCE STRUCTURE

SMALL ZONE OF ATT. GINGIVA

LESS FIBRES

GOLDMAN 1980
EPITHELIAL MIGRATION FOLLOWING DESTRUCTION OF

GINGIVAL FIBRES
REDUCED VASCULATURE & DENSE CONNECTIVE TISSUE

FIBRES
ACT AS A DETERENT TO INITIATION & PROGRESSION OF

PERIODONTAL DISEASE

LANG NP, LOE H - 1972 1 mm ATTACHED GINGIVA ADEQUATE TO MAINTAIN GINGIVAL HEALTH

LINDHE & NYMAN - 1980 WENNSTROM JL - 1987

GINGIVAL RECESSION
LOCATION OF MARGINAL TISSUE APICAL TO CEMENTO-ENAMEL JUNCTION

TYPES
a. ASSOSCIATED WITH MECHANICAL FACTORS b. ASSOSCIATED WITH DESTRUCTIVE PERIODONTAL DISEASES c. ASSOSCIATED WITH TOOTH MALPOSITION, ALVEOLAR BONE DEHISCENCES, HIGH MUSCLE ATTACHMENT & FRENAL PULL, IATROGENIC FACTORS

CLASSIFICATION OF GINGIVAL RECESSION

SULLIVAN & ATKINS -1968
SHALLOW NARROW SHALLOW WIDE DEEP NARROW DEEP WIDE

MILLER 1985
CLASS I- IV APICAL EXTENSION , INTER PROXIMAL TISSUE INTEGRITY & MALOCCLUSION.

MILLER'S CLASSIFICATION OF GINGIVAL RECESSION

I

II

III

IV

OBJECTIVES
WIDENING THE ZONE OF ATTACHED GINGIVA TREATMENT OF ABNORMAL FRENUM SOFT TISSUE GRAFTING FOR GINGIVAL RECESSION CROWN LENGTHENING TO ELIMINATE EXCESSIVE

GINGIVAL DISPLAY

 RIDGE AUGMENTATION

PAPILLA RECONSTRUCTIVE PROCEDURES

SURGICAL EXPOSURE OF UNERUPTED TEETH

REQUIRING ORTHODONTIC MOVEMENT

BONE OR SOFT TISSUE AUGMENTATION AROUND IMPLANTS

THERAPEUTIC END POINT OF SUCCESS

INCREASE IN WIDTH OF ATTACHED GINGIVA INCREASE IN THICKNESS OF MARGINAL TISSUES

REDUCTION IN AMOUNT OF RECESSION

REDUCTION IN ROOT SENSITIVITY IMPROVED ESTHETICS SUBJECTIVE EVALUATION

FACTORS AFFECTING OUTCOME OF SURGERY

ABNORMAL TOOTH ALIGNMENT
ORTHODONTIC CORRECTION INDICATED

ROOTS WITH THIN BONY PLATES

DONNENFELD & GLICKMAN - 1966 MUCOGINGIVAL LINE

DRAWING OF MUCOGINGIVAL LINE DUE TO TISSUE
CONTRACTION IN THE DIRECTION OF CROWN AFTER ELIMINATION OF INFLAMMATION

SURGICAL PROCEDURES

INDICATIONS
AREAS WHERE A CHANGE IN GINGIVAL MARGIN

MORPHOLOGY WOULD FACILITATE PROPER PLAQUE

CONTROL
LOCALIZED SOFT TISSUE RECESSION THIN GINGIVA FACIAL TO TOOTH WHICH IS

PLANNED FOR ORTHODONTIC TOOTH MOVEMENT

TECHNIQUES
GINGIVAL ENHANCEMENT or AUGMENTATION OF DIMENSIONS

ROOT COVERAGE
RIDGE AUGMENTATION REMOVAL OF FRENA

TECHNIQUES FOR GINGIVAL AUGMENTATION

GINGIVAL EXTENSION PROCEDURES OCHSENBEIN 1960 DENUDATION TECHNIQUE STAFFILENO et al 1966 PERIOSTEAL RETENTION (SPLIT FLAP PROCEDURES) FRIEDMAN 1962 APICALLY REPOSITIONED FLAP PROCEDURE

ROBINSON 1963
FENESTRATION or PERIOSTEAL SEPARATION OPERATION

EDLAN & MEJCHAR- 1963

VESTIBULAR EXTENSION OPERATION

Bjorn 1963

FREE GINGIVAL AUTOGRAFTS

DENUDATION TECHNIQUE & PERIOSTEAL RETENTION PROCEDURE

APICALLY REPOSITIONED FLAP PROCEDURE

NABERS - 1954

FRIEDMAN - 1962

INCISIONS

FLAP REFLECTED

CURRETAGE & ROOTPLANING

BONE RECONTOURING

FLAP SUTURED APICALLY

VESTIBULAR EXTENSION OPERATION

EDLAN & MEJCHAR- 1963

STEP I

STEP II

STEP III

STEP IV

STEP V

FREE GINGIVAL AUTOGRAFTS

Bjorn 1963 Nabers 1966 CLASSIC TECHNIQUE
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 ELIMINATION OF POCKETS PREPARATION OF RECIPIENT SITE OBTAIN GRAFT FROM DONOR SITE IDEAL THICKNESS OF GRAFT 1 1.5 mm TRANSFER & IMMOBILIZE THE GRAFT PROTECT DONOR SITE

VARIANT TECHNIQUES
ACCORDIAN TECHNIQUE RATEISCHAK 1983 STRIP TECHNIQUE - HANS et al 1993

CONNECTIVE TISSUE TECHNIQUE EDEL 1974

COMBINATION TECHNIQUE

HEALING OF FREE GINGIVAL GRAFTS

OLIVER, LOE & KARRING 1986

1) 2) 3)

INITIALPHASE ( 0 3 days) REVASCULARIZATION PHASE ( 2- 11 days) TISSUE MATURATION PHASE ( 11-42 days)

HEALING OF GRAFTS
FREE GINGIVAL GRAFT IN POSITION

HEALING PHASES

II

III

HEALING OF GRAFT OF INTERMEDIATE THICKNESS (0.75 mm) - 10& 1/2 weeks THICKER GRAFTS (1.75 mm) - 16 weeks

ROOT COVERAGE TECHNIQUES

I PEDICLE SOFT TISSUE GRAFTS

A) ROTATIONAL FLAPS

LATERAL SLIDING FLAP

PAPILLA FLAP

DOUBLE PAPILLA FLAP

B) ADVANCED FLAPS WITHOUT ROTATION OR LATERAL MOVEMENT COMBINED WITH GTR

II

FREE SOFT TISSUE GRAFTS

1) EPITHELIALZED SOFT TISSUE GRAFTS

2) SUBEPITHELIAL CONNECTIVE TISSUE

GRAFTS

LATERAL SLIDING FLAP - GRUPE & WARREN1956

REMOVAL OF FRENA

FRENECTOMY and FRENOTOMY INDICATIONS a) GINGIVAL RETRACTION & LOCALIZED GINGIVAL RECESSION b) HINDERED ORAL HYGIENE c) HINDERED PROSTHETIC CONSTRUCTION d) DIASTEMA e) TONGUE TIE

LOCALIZED RIDGE AUGMENTATION

SURGICAL PREPARATION OF EDENTULOUS RIDGES TO RECEIVE THE PONTIC

SIEBERT JS 1997
CLASS- I BUCCOLINGUAL LOSS OF TISSUE WITH NORMAL

RIDGE HEIGHT APICOCORONALLY

CLASS- II

APICOCORONAL LOSS OF TISSUE WITH NORMAL RIDGE WIDTH BUCCOLINGUALLY

CLASS- III

COMBINATION RESULTING IN LOSS OF HEIGHT & WIDTH

INDICATIONS

ESTHETICS PHONETICS TO ENHANCE PATIENTS ABILITY TO PERFORM ORAL HYGIENE MEASURES

SOFT TISSUE TECHNIQUES

DE-EPITHELIALIZED CONNECTIVE TISSUE PEDICLE GRAFTS POUCH PROCEDURES FOR SUBEPITHELIAL GRAFTS WEDGE AND INLAY GRAFT PROCEDURES ONLAY GRAFTS COMBINATION WITH GTR PROCEDURES

RECONSTRUCTION OF INTERDENTAL PAPILLA

COMBINATION OF ORTHODONTIC,RESTORATIVE AND PERIODONTAL TREATMENT REQUIRED FOR OPTIMUM RESULTS

CONNECTIVE TISSUE GRAFTS 1) SERIALLY LAYERED DOUBLE CTG TECHNIQUE 2) PALATAL POUCH PROCEDURE 3) IN COMBINATION WITH BONE GRAFT MATERIALS AND WITH ENAMEL MATRIX DERIVATIVES

CRITERIA FOR SELECTION OF TECHNIQUES

1)

POCKETS EXTENDING UPTO MGJ a) APICALLY POSITIONED FLAP b) FREE MUCOSAL GRAFTS ABSENCE OF ATTACHED GINGIVA 1) FREE GINGIVAL GRAFT 2) NO TREATMENT

2)

3) ROOT COVERAGE I LANGER & LANGER TECHNIQUE

II TARNOWS - FOR ISOLATED UPPER TEETH III GTR- TECHNIQUE DEEP RECESSION DEFECTS

CONCLUSION

LONG TERM STUDY RESULTS NEWER TECHNIQUES BONE AND SOFT TISSUE AUGMENTATION

AROUND IMPLANTS