Mucogingival Surgeries

Patricia Miguez, DDS, MS, PhDDepartment of Periodontics

Plastic Periodontal Surgery

Goals

Halting gingival recession Increasing width of attached

gingiva

Deepening the vestibulum Covering areas of gingival recession

Surgical Techniques

Frenectomy/ Frenotomy Free gingival graft

Frenotomy- surgical separation of the frenum pull

Frenectomy- complete removal of the entire frenum

Frenectomy

John Ruch

John Ruchremove and then stitch together the mucosa, no painful really, heals fast

John Ruchdiamond shape because you try to preserve as much tissue next to the crown

Free gingival graft(Bjrn 1963; Sullivan & Atkins 1968)

Replacement or enhancement of the mobile, non-keratinized mucosa with keratinized gingiva

Usually harvested from palate

John Ruchcan also be harvested from the retromolar area

Free gingival graft(Bjrn 1963; Sullivan & Atkins 1968)

Indications!Halting process of recession formation, widening band of keratinized gingiva

!Mucogingival defect beyond the MGJ, thus oral hygiene rendered difficult

John Ruchhave not been showed to predictably cover roots, can get some root cover, but not predictable (instead use a CT graft)

Free gingival graft(Bjrn 1963; Sullivan & Atkins 1968)

Contraindications!Esthetic concerns (whitish color of graft)

!Stationary recession accessible for OH and lack inflammation

John Ruchtends to have the color of the palate compared to other areas (color of the mucosa) throughout the mouth, never completely blends in

John Ruchdoes not form a knife edge with the teeth normally so you might have to perform a second surgery to get the desired results

Free gingival graft -Healing Graft thickness at least 1 mm 2 days after surgery parts of epithelium desquamate,

graft appears necrotic

New epithelialization from gingival margin of recipient site

After 1 week graft has healed into bed and has new epithelium

Complete keratinization after 4 weeks Palatal wound re-epithelializes in 1-2 weeks

Mucosa growing over graft turn into keratinized tissue

John Ruchnote

John Ruchjust part of the healing, does not look pretty, discuss with ptahead of time

John Ruchnote

John Ruchpretty painful because its the route for food and drinks, some practitioners like to make trays for the palate to protect

Roll-Test

assess amount of attached gingiva

John Ruchsometimes the mucosa has the same color as the attached gingiva and so you don't know until you do this test

Schematic Incision Design for FGG

John Ruchnot just bone but also a layer of periosteum (tissue ontop of the bone)- can suture the new grafted tissue to the layer of tissue

Post-orthodontic treatment

John Ruchpretty thin biotype, pretty deep localized recession, flap cut at the mesial and distal site of the teeth- dissected so that if you pull the lip, the graft should not move, if it does then you need to release more

John Rucha little bit resorbable and a little non resorbable so that they know the graft will be stable

John Ruchput something here to protect the area- listen

2 weeks post-op

John Ruchpretty tender still and does not look too natural, tends to improve with time, but remains patchy looking

4 weeks post-op

4 months post-op

Plastic Periodontal Surgery

GoalsHalting gingival recessionIncreasing width of attached gingivaDeepening the vestibulum

Covering areas of gingival recession

John Ruchfree gingival graft is not the most indicated, usually instead its the CT graft (pedicle graft- rotate into place)

Surgical techniques Pedicle flap Free gingival graft (FGG) Connective Tissue Graft (CTG) Guided Tissue Regeneration (GTR) Growth Factors and enamel matrix

proteins (EMD)

Erica Damante

Erica Damante

John Ruchtricky

John Ruch

John Ruchshows the highest rate of success for gingival recession

John Ruchone of the hardest to achieve- depend on membrane not moving, depend on skills, and also pt compliance- (pt cannot move the graft at all- not to clean the area)

John Ruch

John Ruch

John Ruchcombining something like enamel matrix and CT grat will boost the outcome

Predisposing Factors for mucogingival problems

Thin facial osseous anatomy Thin biotype Coronally attached frena Shallow vestibulum

John Ruchapical recession of the gingiva

Mucogingival Defects

Inappropriate and/ or excessive oral hygiene

Periodontal Disease Bruxism/ clenching leading with

abfractions (?)

John Ruchheavy occlusal loads- some people say they can cause recession and some say they cannot- heavy occlusal forces can make an inflammatory process progress faster

Classification of Recession (Miller 1985)

Miller Class I

Wide or narrow defect isolated to facial aspect

Papillae filling interdental areas

Defect not extending beyond MGJ

100% root coverage, e.g. CTG

John Ruchsome recession either palatal or facial- does not cross the MGJ- very concentrated to the one area of the tooth-high chance that the graft to that area will survive and stay because there is a lot of surrounding nutrition

Miller Class II

Narrow and wide defect extending beyond MGJ

Papillae remain intact Tx:100% coverage can be

achieved, e.g. GTR

John Ruchstill narrow and predictabble granted you can secure and attach the graft well

Miller Class III Broad recession extending

beyond MGJ into mucosa

Interdental papilla may be lost due to malpositioning, shrinkage

Tx: 100% coverage NOT possible, rebuilding papillae hopeless

John Ruchstart to lose tissue interproximally- can you place a free gingival graft and extend to the adjacent teeth and tissues (not really)

John Ruchnote

Miller Class IV

Loss or hard and soft tissue around entire tooth due to periodontal disease

Tx: Regeneration of lost tissues only rarely possible

John Ruchinverted anatomy, the worst interproximal loss

Recession coverageIndications

Esthetics Hypersensitive root surfacesWedge-shaped defects at cervical areasrisk of root caries

John Ruch

John Ruchnot indicated everywhere, before going to surgical solution for sensitivity- may try sensitivity toothpastes, desensitizers, or fluoride treatments

John Ruchalloderm- CT graft from cadavers

Recession CoverageTechniques

Pedicle flaps (coronally, laterally, rotated)

FGG CTG GTR Bioactive proteins (e.g. Emdogain + CTG)

Lateral Sliding Pedicle Flap

Sufficient amount of keratinized attached gingiva at adjacent site

Grupe & Warren 1956

John Rucha little tricky not to cause recession to the adjacent tooth- dont scale the root of the tooth B because you want the PDL to remain

Coronally advanced flap

Allen & Miller 1989

John Ruchjust moving the tissue downward- as you reach the vestible you move it down, have to remove the epithelium before you move the flap downward otherwise it will not work- should move the flap 1-2 mm further coronal from the CEJ

Semilunar pedicle flap

Tarnow 1986

John Ruchthis is very predictable but estehtically hard to ahcieve a nice result

John Ruchpedicle versus FGG versus other procedures- use for reference

Zucchelli & DeSanctis 2000

John Ruchmultiple recession areas- triangle shapes in the papilla- go slowly with a really small blade- denude the interproximal ares and then pull down the flap and then suture in place- you have to have attached gingiva in place- have to have at least 3 mm of attached gingiva beyond the recession in order to be completed predictably

4 different CTG techniques HorizonaL incisions at CEJ

and gingival margin

Vertical releases beyond MGJ Split thickness CTG from palate (or

Alloderm)

Covering recession with graft at CEJ

Partial covering of graft with flap

Langer & Langer 1985

John Ruchplace CT graft first- will develo attached giginva over time? put the CT graft down first and then flap the attached gingiva over top it- with time it will develop some attached gingiva

Connective Tissue Graft(Langer & Langer 1985)

Partially or completely covered with gingiva and/ or mucosa

On average 90% success in esthetic coverage

Bilaminar blood supply golden standard for root coverage

procedures

John RuchCT grafts are very forgiving

John Ruchif you also place a flap ontop as well as the blood supply from below- higher rate of success

Connective Tissue Graft Uneven root surfaces should be flattened Removal of smear layer? Coronal area of healed site is long epithelial

attachment

Apical area connective tissue attachment Thickness: 1.5 -2 mm CTG could also be used for soft tissue ridge

augmenatation procedures

John Ruchacid removes mineral from the roots- exposes the collagen- that collagen might interact with the collagne of the CT- well its not really true . It can happen, but there really is no need for the acid tx. All you have to do is clean the root surface to ensure that it is plaque free

John Ruchneed or else might become necrotic

John Ruchpre-prosthetic concern

Harvesting of graft; Donor sites

Incisions 2mm removed from gingival margins

John Ruchtry not to go in the area of the second molar-

Incision design for CTG harvesting

John Ruchif FGG then you dont have to cut it

John Ruchpiece of CT graft, placed in the area of recession, after the CT was placed and sutured in place - graft the flap and flap over top the graft- if there is CT exposed still it is fine because it will be covered by epithelium eventually

Full-thickness flap CTG at CEJ Covering graft by laterally positioning flaps Bilaminar nourishment for graft

Soft tissue flap Interdental bone

Nelson 1987

John Ruchcombination of pedicle graft flaps on top of CT graft

should really provide blood supply ontop, from the sides, and from below for the greatest chance of success

Harris 1992

Horizontal incisions Vertical incision mesial and distal to tooth treated Split-thickness CTG over recession Joining tips of the flaps over area of recession Nutrition from flaps and periosteum

Bruno 1994

Envelope technique No vertical incisions Split-thickness CTG into envelope suturing of flaps and CTG

Guided Tissue Regeneration for root coverage procedures

Resorbable and non-resorbable membranes have been suggested

Recent studies showed similar results CTG versus GTR with regard to root coverage %

Alloderm grafting material

John Ruchpiece of mostly collagen harvested from cadavers- decellularized- no cells present, best not to leave exposed- parts that are exposed will become completely necrotic (smells, looks terrible)- she doesnt like alloderm- if you are succesful in covering it it is as successful as a CT graft however its not as firm as attached gingiva (looks more like mucosa)- its healthy but doesn't look healthy

2 weeks post-op

John Ruchwith alloderm it looks red, with CT graft it would look more pink, for some patients you have to use alloderm because there is not tissue available for graft on the palate

Thank you