muco gingival surgery
TRANSCRIPT
PERIODONTAL PLASTIC PERIODONTAL PLASTIC AND ESTHETIC AND ESTHETIC
SURGERYSURGERY
Dr Deepak ChopraDr Deepak Chopra
DefinitionDefinition
Periodontal Plastic SurgeryPeriodontal Plastic Surgery is defined is defined as the procedures performed to correct the as the procedures performed to correct the anatomical, developmental and traumatic anatomical, developmental and traumatic deformities of gingiva and alveolar deformities of gingiva and alveolar mucosa. mucosa.
Terminology Terminology
Periodontal Plastic Surgery was previously Periodontal Plastic Surgery was previously termed as Muco-Gingival surgery termed as Muco-Gingival surgery
The term Periodontal Plastic Surgery was The term Periodontal Plastic Surgery was originally introduced by Miller in 1993. originally introduced by Miller in 1993.
AAP world workshop 1996 renamed Muco AAP world workshop 1996 renamed Muco Gingival Surgery as Periodontal Plastic Gingival Surgery as Periodontal Plastic Surgery. Surgery.
ObjectivesObjectives
To correct the problems associated with To correct the problems associated with inadequate attached gingiva. inadequate attached gingiva.
To correct the problems associated with To correct the problems associated with shallow vestibule.shallow vestibule.
To correct the problems associated with To correct the problems associated with high frenum attachment.high frenum attachment.
Indications of periodontal plastic Indications of periodontal plastic surgerysurgery
Periodontal prosthetic surgery Periodontal prosthetic surgery Crown lengthening surgery Crown lengthening surgery Ridge augmentation surgery Ridge augmentation surgery Esthetic surgical correction.Esthetic surgical correction.Coverage of denuded root surface Coverage of denuded root surface Reconstruction of papilla.Reconstruction of papilla.Esthetic surgical correction around Esthetic surgical correction around implants implants
Rationale Rationale
Rationale of periodontal plastic surgery Rationale of periodontal plastic surgery was previously predicated on the was previously predicated on the assumption that a minimum width of assumption that a minimum width of attached gingiva is essential to maintain attached gingiva is essential to maintain optimum gingival health.optimum gingival health.
PROBLEMS ASSOCIATED WITH PROBLEMS ASSOCIATED WITH INADEQUATE WIDTH OF INADEQUATE WIDTH OF
ATTACHED GINGIVAATTACHED GINGIVA
Normal GingivaNormal Gingiva
Gingival and periodontal structuresGingival and periodontal structures
Problems Associated With Problems Associated With Inadequate Width of Attached Inadequate Width of Attached
GingivaGingiva1.1. Difficulty in maintaining Optimum Difficulty in maintaining Optimum
Gingival Health.Gingival Health.
2.2. Improper plaque control.Improper plaque control.
3.3. Difficulty in maintaining Optimum Difficulty in maintaining Optimum Gingival Health around abutment teeth.Gingival Health around abutment teeth.
4.4. Inadequate keratinized tissue for Inadequate keratinized tissue for placement of RPD.placement of RPD.
Measurement of Width of Attached Measurement of Width of Attached GingivaGingiva
Width of attached gingiva can be Width of attached gingiva can be measured by subtracting pocket depth measured by subtracting pocket depth from the distance between free gingival from the distance between free gingival margin to the mucogingival junction.margin to the mucogingival junction.
Measurement of Width of Attached Measurement of Width of Attached Gingiva and Keratinized Gingiva Gingiva and Keratinized Gingiva
Advantages of Creating Adequate Advantages of Creating Adequate Width of Attached GingivaWidth of Attached Gingiva
1.1. Proper plaque removal.Proper plaque removal.
2.2. Improved esthetics.Improved esthetics.
3.3. Reduces inflammation around restored Reduces inflammation around restored teeth.teeth.
Techniques For Increasing Width of Techniques For Increasing Width of Attached GingivaAttached Gingiva
1.1. Free gingival autograft,Free gingival autograft,
2.2. Free connective tissue autograft,Free connective tissue autograft,
3.3. Apically positioned flap,Apically positioned flap,
4.4. Pedicle autograft,Pedicle autograft,
5.5. Subepithelial connective tissue autograft.Subepithelial connective tissue autograft.
Problems Associated With Shallow Problems Associated With Shallow VestibuleVestibule
1.1. Improper plaque removal,Improper plaque removal,
2.2. Difficulty in placement of removable Difficulty in placement of removable prosthesis.prosthesis.
SHALLOW VESTIBULE
NORMAL VESTIBULAR
DEPTH
Measurement of Vestibular DepthMeasurement of Vestibular Depth
Depth of vestibule is measured from gingival Depth of vestibule is measured from gingival margin to the bottom of the vestibule.margin to the bottom of the vestibule.
Advantages of Creating Adequate Advantages of Creating Adequate Vestibular DepthVestibular Depth
1.1. Proper plaque control.Proper plaque control.
2.2. Proper tooth brushing.Proper tooth brushing.
3.3. Proper placement of removable Proper placement of removable prosthesis.prosthesis.
TECHNIQUESTECHNIQUES
VESTIBULAR DEEPENING (EDLAN- VESTIBULAR DEEPENING (EDLAN- MEJCHAR’S)MEJCHAR’S)
FENESTRATION OPERATIONFENESTRATION OPERATION
FREE SOFT TISSUE AUTOGRAFTFREE SOFT TISSUE AUTOGRAFT
PROBLEMS ASSOCIATED WITH PROBLEMS ASSOCIATED WITH HIGH FRENUMHIGH FRENUM
IMPROPER PLAQUE REMOVALIMPROPER PLAQUE REMOVAL
TENSION ON THE FRENUM MAY TEND TENSION ON THE FRENUM MAY TEND TO OPEN THE SULCUSTO OPEN THE SULCUS
NORMAL FRENUM ATTACHMENT
HIGH FRENUM ATTACHMENT
EXAMINATION OF HIGH EXAMINATION OF HIGH FRENUMFRENUM
TENSION TEST IS PERFORMED BY TENSION TEST IS PERFORMED BY PULLING THE LIPS : IN CASES OF PULLING THE LIPS : IN CASES OF HIGH FRENUM, THERE IS BLANCHING HIGH FRENUM, THERE IS BLANCHING OF THE GINGIVA AND MOVEMENT OF OF THE GINGIVA AND MOVEMENT OF GINGIVAL MARGIN ALONG WITH THE GINGIVAL MARGIN ALONG WITH THE MOVEMENT OF CHEEKS AND THE MOVEMENT OF CHEEKS AND THE LIPSLIPS
ADVANTAGES OF CORRECTING ADVANTAGES OF CORRECTING HIGH FRENUM ATTACHMENTHIGH FRENUM ATTACHMENT
1.1. Proper plaque control.Proper plaque control.
2.2. Reduces inflammation of the gingiva Reduces inflammation of the gingiva around teeth.around teeth.
3.3. Reduces progression of periodontal Reduces progression of periodontal diseasedisease
TECHNIQUESTECHNIQUES
FRENOTOMYFRENOTOMY
FRENECTOMYFRENECTOMY
GINGIVAL RECESSIONGINGIVAL RECESSION
DEFINITION:DEFINITION:
EXPOSURE OF THE TOOTH BY THE EXPOSURE OF THE TOOTH BY THE APICAL MIGRATION OF THE GINGIVAAPICAL MIGRATION OF THE GINGIVA
EXPOSURE OF THE ROOT SURFACE EXPOSURE OF THE ROOT SURFACE BY AN APICAL SHIFT IN THE POSITION BY AN APICAL SHIFT IN THE POSITION OF THE GINGIVAOF THE GINGIVA
NO GINGIVAL RECESSION GINGIVAL RECESSION IN RELATION TO MANDIBULAR CENTRAL INCISOR
ETIOLOGYETIOLOGY
FAULTY TOOTH BRUSHING( GINGIVAL FAULTY TOOTH BRUSHING( GINGIVAL ABRASION)ABRASION)
TOOTH MALPOSITIONING.TOOTH MALPOSITIONING.
FRICTION FROM SOFT TISSUE FRICTION FROM SOFT TISSUE (GINGIVAL ABLATION)(GINGIVAL ABLATION)
GINGIVAL INFLAMMATIONGINGIVAL INFLAMMATION
HIGH FRENUM ATTACHMENTHIGH FRENUM ATTACHMENT
Periodontal Plastic SurgeryPeriodontal Plastic Surgery
Periodontal Plastic SurgeryPeriodontal Plastic Surgery
CLASSIFICATION OF GINGIVAL CLASSIFICATION OF GINGIVAL RECESSIONRECESSION
SULLIVAN AND ATKIN’SSULLIVAN AND ATKIN’S
•SHALLOW –NARROWSHALLOW –NARROW•SHALLOW –WIDESHALLOW –WIDE•DEEP- NARROWDEEP- NARROW•DEEP- WIDEDEEP- WIDE
CLASSIFICATION OF GINGIVAL CLASSIFICATION OF GINGIVAL RECESSIONRECESSION
TECHNIQUES TO MANAGE TECHNIQUES TO MANAGE GINGIVAL RECESSIONGINGIVAL RECESSION
FREE GINGIVAL AUTOGRAFTFREE GINGIVAL AUTOGRAFT
PEDICLE AUTOGRAFTPEDICLE AUTOGRAFT
FREE CONNECTIVE TISSUE FREE CONNECTIVE TISSUE AUTOGRAFTAUTOGRAFT
SUBEPITHELIAL CONNECTIVE TISSUE SUBEPITHELIAL CONNECTIVE TISSUE AUTOGRAFTAUTOGRAFT
GUIDED TISSUE REGENERATIONGUIDED TISSUE REGENERATION
MILLER’S CLASSIFICATIONMILLER’S CLASSIFICATION
Millers Class I RecessionMillers Class I Recession
Miller Class I RecessionMiller Class I Recession
Class IClass I
Marginal tissue recession which doesMarginal tissue recession which does
not extend to the mucogingival junctionnot extend to the mucogingival junction
No periodontal bone loss in the No periodontal bone loss in the
interdental areainterdental area
100% root coverage100% root coverage
Millers Class II RecessionMillers Class II Recession
Millers Class II RecessionMillers Class II Recession
Class IIClass II
Marginal tissue recession which extendsMarginal tissue recession which extends
to or beyond the mucogingival junctionto or beyond the mucogingival junction
No periodontal loss in the interdental areaNo periodontal loss in the interdental area
100% root coverage100% root coverage
Millers Class III RecessionMillers Class III Recession
Millers Class III RecessionMillers Class III Recession
Marginal tissue recession which extendsMarginal tissue recession which extends
to or beyond the mucogingival junctionto or beyond the mucogingival junction
Bone or soft tissue loss in the interdental area Bone or soft tissue loss in the interdental area
or malpositioning of the teeth, preventing or malpositioning of the teeth, preventing
100% root coverage100% root coverage
Partial root coverage Partial root coverage
Millers Class IV RecessionMillers Class IV Recession
Millers Class IV RecessionMillers Class IV Recession
Class IVClass IV
Marginal tissue recession which extendsMarginal tissue recession which extends
to or beyond the mucogingival junctionto or beyond the mucogingival junction
Severe bone or soft tissue loss in theSevere bone or soft tissue loss in the
interdental area and/or malpositioning of teethinterdental area and/or malpositioning of teeth
No root coverageNo root coverage
Root Coverage Using FreeRoot Coverage Using FreeAutogenous Gingival GraftsAutogenous Gingival Grafts
IndicationsIndications
All cases where root coverage is necessaryAll cases where root coverage is necessary
except when a graft of sufficient thicknessexcept when a graft of sufficient thickness
(1.5-2.0 mm) cannot be harvested(1.5-2.0 mm) cannot be harvested
ContraindicationsContraindications
Extensive gingival recessionExtensive gingival recession
Esthetic casesEsthetic cases
Root Coverage Using FreeRoot Coverage Using FreeAutogenous Gingival GraftsAutogenous Gingival Grafts
DisadvantagesDisadvantages
Poor ability to provide blood supply to thePoor ability to provide blood supply to the
graft for root coveragegraft for root coverage
Exposed deep and large wound on theExposed deep and large wound on the
palatal mucosapalatal mucosa
Inferior esthetic results due to scarringInferior esthetic results due to scarring
Surgery required in 2 areasSurgery required in 2 areas
preoperativepreoperative
IncisionsIncisions
Epithelial Surface RemovedEpithelial Surface Removed
Donor SiteDonor Site
Free Gingiva Graft HarvestedFree Gingiva Graft Harvested
Graft Placed at Recipient SiteGraft Placed at Recipient Site
Root Coverage & Increase In Attached Root Coverage & Increase In Attached Gingiva PostoperativelyGingiva Postoperatively
Connective Tissue GraftsConnective Tissue Grafts
Connective Tissue GraftsConnective Tissue Grafts
88% root coverage in areas of severe88% root coverage in areas of severe
gingival recessiongingival recession
Greater amount of root coverage and rateGreater amount of root coverage and rate
of complete coverage with the use ofof complete coverage with the use of
connective tissue grafts as compared toconnective tissue grafts as compared to
free gingival graftsfree gingival grafts
Root Coverage UsingRoot Coverage UsingConnective Tissue GraftsConnective Tissue Grafts
AdvantagesAdvantages
High predictabilityHigh predictability
Graft receives abundant blood supply from 2 Graft receives abundant blood supply from 2
sourcessources
Wound closed at palatal donor site afterWound closed at palatal donor site after
harvest of connective tissue graftharvest of connective tissue graft
Esthetically pleasing resultsEsthetically pleasing results
Applicable for gingival recession on multiple Applicable for gingival recession on multiple
teethteeth
Root Coverage UsingRoot Coverage UsingConnective Tissue GraftsConnective Tissue Grafts
DisadvantagesDisadvantages
Technically demandingTechnically demanding
Gingivoplasty may be necessaryGingivoplasty may be necessary
postoperativelypostoperatively
Multiple RcessionsMultiple Rcessions
Recepient Site IncisionsRecepient Site Incisions
Reflection of FlapReflection of Flap
Donor SiteDonor Site
CT Graft Placed at Recipient SiteCT Graft Placed at Recipient Site
Flap placed over ct graft & suturedFlap placed over ct graft & sutured
Donor site flap sutured backDonor site flap sutured back
Postoperative root coveragePostoperative root coverage