history of flaps

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Perio Plastic Surgery

Mucogingival Jeopardy

History of Periodontal Plastic Surgery

!1930s Frenectomies performed as well as deepening of the mucobuccal

fold!1948 Goldman performed the first gingivoplasty

!1956 Warren & Grupe showcase the Laterally Positioned Flap

!1962 Friedman introduces the Apically Positioned Flap and the internal

beveled incision

!1963 Bjorn introduces the Free Gingival Graft

!1982 P.D. Miller introduces the FGG for root coverage

Fernandez first to do CTG

Pini Prato performs first GTR procedure

!1989 AAP renames Mucogingival Surgery to Periodontal Plastic

Surgery

Caranzza

Definitions

!Mucogingival Defect a departure from the normal

dimension and morphology of the the relationship

between the gingiva and the alveolar mucosa.

!Mucogingival Surgery periodontal

surgical procedure to correct defects in

morphology, position, and/or amount of

gingiva.

Definitions

!Periodontal Plastic Surgery Procedure

surgical procedure performed to correct or

eliminate anatomic, developmental, or

traumatic deformities of the gingiva and

alveolar mucosa.

Criteria for Periodontal Plastic

Surgery Procedures

!Surgical site free of plaque, calculus, and inflammation

!Must maintain adequate blood supply

!Be familiar with the anatomy of the recipient and donor site

!Ensure the stability of the grafted tissue

!Minimize trauma to the surgical site. Be kind to the tissue and it

will be kind to you.

Dr. Deby JohnsonPeriodontology III

Spring Semester, 2012School of Dentistry

University of Minnesota

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Indications for Periodontal Plastic Surgery

!Root coverage

!Gingival Augmentation

"Coronally positioned flap

"Semilunar flap

"Laterally positioned flap

"Double papilla flap

"FGG

"CTG

"GTR

"Free gingival graft (FGG)

Keratinized Gingiva. How much do you need?

Bowers 63 felt gingival health could be maintained with a

narrow zone of KG (


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With FGG allow for

shrinkage of between

25 to 50 % of the graft

FGG for Gingival AugmentationFGG for Gingival Augmentation

NOT for root coverage

Incisions placed Graft harvested

FGG for Gingival Augmentation

Sutured in place

FGG for Gingival Augmentation

(NOT Root Coverage)

1 week post-op 3 weeks post-op

Downloaded from: Carranzas Clinical Periodontology (on 10 August 2006 10:25 PM)

2005 Elsevier

FGG with secondary Coronal

Positioning

Millers Class I Gingival Recession

-Defect coronal to MGJ

-Interprox bone andpapillae intact, nomalpositioning

-100% Coverage




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Millers Class II Gingival Recession

-Recession or AL beyond the

MGJ

-No bone , papillae loss or

malposition

-100% coverage expected

Miller Class

212

11

23

Miller Class

211

1

12

Millers Class III Gingival Recession

-Recession or AL to or

beyond the MGJ- Some bone , papillae loss or

tooth malposition present

-Only partial root coverage

can be expected

Millers Class IV Gingival Recession

-Recession or AL to orbeyond the MGJ

- Extreme interproximal bone/

papillae loss or extreme tooth

malposition present(horizontal bone loss)

-No root coverage can be

expected

! In some cases of very thin tissue, tissue

augmentation may be done to increasethe thickness of the existing tissue formore stability.




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Factors Associated with Incomplete

Root Coverage

!Improper classification

!Inadequate root preparation

!Inadequate papilla size

!Improperly prepared donor tissue

!Inadequate graft size/thickness

!Dehydration of graft ( < 30 min)

!Smoking

P. D. Miller

Pedicle Gingival Grafts

Coronally Positioned Flap

Indications

!Recession with adequate gingiva

!Esthetics

!Root sensitivity

Advantages

!Easier to treat multiple sites

!Predictable root coverage

!Good color match

Disadvantages

!Limited by height of papilla

!Multiple surgical procedures if combined with FGG/CTG procedure


Coronally Positioned Flap


2005 Elsevier

Semilunar Coronally Postioned

Flap


Laterally Positioned Flap

Preparation of recipient sitePre-op view




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Graft is mobilizedGraft sutured in place



10 days post-op 12 weeks post-op

FGG for Root Coverage

Pre-op view Root planing performed and

modifiers applied


Incisions made at recipient site Partial thickness flap reflected


Donor tissue outlined... and harvested


Harvested graft should be 1.5-2.5

mm thick for root coverage

purposes




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Graft tried in place Graft sutured in place


2 weeks post-op 8 weeks post-op


2005 Elsevier

Connective Tissue Grafts /

Sub-epithelial Connective

Tissue Grafts

Outline of incisions at

recipient site

Partial thickness flap

reflected



Tissue Grafts

Area root planed and... Tetracycline applied



Tissue Grafts

Graft outlined Graft harvesting




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Graft Harvesting for CTGConnective Tissue Grafts /


Tissue Grafts

Harvested graft

EPI

CT



Tissue Grafts

Graft approximated... And sutured into place



Tissue Grafts

Flap is repositioned over graft and

sutured into place



Tissue Grafts

2 weeks post-op 10 weeks post-op



Tissue GraftsModified Technique

!Does not utilize a vertical incision when preparing the recipient site

!Ensures excellent blood supply to flap

!Avoids scarring in esthetic areas

Pre-op viewRoot planing performed and

TCN applied




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Tissue Grafts

Modified Technique

Incisions placed Partial thickness flap reflected



Tissue Grafts

Modified Technique

Graft approximated Flap coronally positioned

and sutured



Tissue GraftsModified Technique

10 days post-op 3 weeks post-op

Connective Tissue Graft Using an

Envelope Flap

Raetzke Technique

Pre-op view

Connective Tissue Graft

Using an Envelope Flap

Raetzke Technique

SC/RP performed TCN applied

Connective Tissue Graft Using

an Envelope Flap

Raetzke Technique

Papilla is undermined




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Connective Tissue Graft Using

an Envelope Flap

Raetzke Technique



Raetzke Technique

Harvested graft Graft try-in



Raetzke Technique



Raetzke Technique

1 week post-op 3 weeks post-op


2005 Elsevier




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history of flaps

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