036. mucogingival surgery

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Mucogingival Surgery Also named as periodontal plastic surgery “Surgical procedures performed to correct or eliminate anatomic, developmental or traumatic deformities of the gingiva or alveolar mucosa” “Periodontal surgical procedures designed to correct defects in the morphology, position and/or amount of gingiva surrounding the teeth” “plastic surgical procedures for the correction of gingiva, mucous membrane relationships that complicate periodontal diseases and may interfere with the success of periodontal treatment”


Mucogingival Problems

i. Pockets extending up to or beyond mucogingival junction ii. Recession causing denudation of root surfaces iii. High frenum and muscle attachments iv. Inadequate width of attached gingival.

Objectives

1. Widening the zone of attached gingiva 2. Coverage of denuded roots 3. Removal of aberrant frenum. 4. Creation of some vestibular depth when it is lacking. 5. As an adjunct to routine pocket elimination procedures.

Indications

1. Augmentation of the edentulous ridge. 2. Prevention of ridge collapse associated with tooth extraction. 3. Crown-lengthening. 4. Loss of interdental papilla which presents as esthetic/or phonetic defect.


Contraindications

• Gingival augmentation procedures for correction of mucosal defects (around implants) • Root coverage procedures • Gingival preservation at ectopic tooth eruption • Removal of aberrant frenulum • Ridge augmentation • Crown-lengthening procedures.

Techniques To Increase The Width Of Attached Gingiva Free Soft Tissue Autograft Techinques • Classic technique • Variant techniques.

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The Classic Technique Step 1: Eliminate the pockets Step 2: Preparation of the recipient site Step 3:Obtaining the graft from the donor siteStep 4: Transfer and immobilization of the graftStep 5: Protection of the donor site

Step 3:Obtaining the graft from the donor site Step 4: Transfer and immobilization of the graft

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Variant Techniques

Four variants to the classic technique are described: a. Accordion technique b. Strip technique c. The connective tissue technique d. Combination of strip and connective tissue techniques.


Accordion Technique

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Strip Technique

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Connective Tissue Technique Advantages of this technique include: a. Donor site—Healing by primary intention is achieved because the donor material can be obtained from connective tissue that is present beneath the palatal flap. b. Color matching is better.


Combination Techniques It can be performed as follows: Remove a strip of tissue about 3 to 4 mm thick from the palate, place it between two wet tongue depressors, and slice it longitudinally with a sharp BP blade. Use a superficial portion that contains epithelium and connective tissue. And the deeper portion that only consists of connective tissue.


Healing Of The Graft I. Plasmatic Circulation Stage (2-3 Days): Direct joining of capillaries between the graft and the recipient bed is seen and capillaries of the recipient bed invade the graft. Ii. Capillary Circulation Stage (4-5 Days): Capillaries start functional circulation again. The epithelium at this stage is almost desquamated and sparse. Iii. Organization Stage (10-14 Days): Organization is completed by growth of fibroblasts in the graft and in the recipient bed. The network of capillaries become dense. Regeneration of epithelium becomes active to complete the epithelialization (wound healing is by secondary intention)


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Apically-Displaced Flap Pocket elimination widening the zone of attached gingival. can be a full thickness (or) split thickness flap

Procedure

Step I : Internal bevel incision 0.5-1 mm from the crest of the marginal gingiva is given. Step II : Crevicular incision and interdental incisions are placed. Step III : Vertical incisions extending beyond the mucogingival junction are made so that the flap can be displaced easily. Reflect the flap depending on the purpose (split thickness or full thickness). Step IV : Debride the area and place the flap apical to its original position and suture.


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Techniques For Widening The Zone Of Attached Gingiva Fenestration Operation/Periosteal Separation Utilizes a partial thickness flap

Techniques For Widening The Zone Of Attached Gingiva

Fenestration Operation/Periosteal Separation

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Vestibular Extension Operation For the widening of attached non-keratinizing tissue. two vertical incisions from the junction of the marginal and attached gingiva to approximately 12 mm from the alveolar margin into the vestibule. The vertical incisions are joined by horizontal incision. A mucosal flap is elevated exposing the periosteum on the bone. The periosteum is separated from the bone, starting from the line of attachment of the mucosal flap. The periosteum including muscle attachments is transported to bone and is sutured to the inner surface of the periosteum.


Root Coverage

Advantages for root coverage procedures i. Reduces root sensitivity. ii. Improves esthetics. iii. Manage the defects resulting from root caries removal and/or cervical abrasions. iv. Manage mucogingival defect which fail to respond to altering abusive tooth-brushing techniques and/ or plaque removal.


Classification Sullivan and Atkins, 1960 i. Shallow-narrow. ii. Shallow-wide. iii. Deep-narrow. iv. Deep-wide


Miller’s Classification (1985) Class I: Marginal tissue recession that does not extend to the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be narrow or wide Class II : Marginal tissue recession that extends to or beyond the mucogingival junction. There is no loss of bone and soft tissue in the interdental area. This type of recession may be wide or narrow. Class III : Marginal tissue recession that extends to or beyond the mucogingival junction. In addition, there is bone and/or soft tissue loss interdentally or tooth may be malposed. Class IV : Marginal tissue recession extends to or beyond the mucogingival junction. With severe bone and soft tissue loss interdentally and/or severe tooth malposition.


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Type of recession Prognosis

Class I and II Good to excellent Class III Only partial coverage can be expected Class IV Very poor


Procedures For Root Coverage 1. Conventional procedures. 2. Regenerative procedures.

Conventional procedures Depending on the width of the attached gingiva, i.e. if adequate width is present at the donor site the following procedures can be selected:

a. Laterally (horizontally) displaced flap. b. Double-papilla flap. c. Coronally-positioned flap

If the donor site is associated with inadequate width: i. Free soft tissue autograft. ii. Subepithelial connective tissue grafts are available

Regenerative procedures: Guided tissue regeneration (GTR) has been proposed. Pedicle autografts:


Laterally (Horizontally) displaced flap Advantages a. One surgical site b. Good vascularity of the pedicle flap. c. Ability to cover isolated, denuded roots that have adequate donor tissue laterally. Disadvantages a. Limited by the amount of adjacent keratinized attached gingiva. b. Possibility of recession at the donor site. c. Dehiscence or fenestration at the donor site. d. Limited to one or two teeth with gingival recession. Indications: a. For covering the isolated denuded root. b. When there is sufficient width of interdental papilla in the adjacent teeth. c. Sufficient vestibular depth. Contraindications: a. Presence of deep interproximal pockets. b. Excessive root prominence. c. Deep or extensive root abrasion or erosion. d. Significant loss of interproximal bone height.


Procedure for laterally displaced flap: Step I : Preparation of the recipient siteIncision 3 insions SRP of the recipient bed thickness or full thickness reflection short obliquethe flap, pointing more towards the recipient sit Step II : Transfer the flap Suturing to the adjacent gingival and alveolar mucosa with interrupted suture Step III : Protect the flap and donor site periodontal pack for 1 week Antibiotics optional Analgesic mandatory

e of the recipient bed removal of GT flap is then raised utilizing either partial

short oblique incision into the alveolar mucosa at the distalrecipient site.

alveolar mucosa with interrupted sutures

e

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flap is then raised utilizing either partial incision into the alveolar mucosa at the distal corner of


Double papilla flap Indications: 1. When the interproximal papillae adjacent to the mucogingival problem are sufficiently wide. 2. When the attached gingiva on an approximating tooth is insufficient to allow for a Lateral Pedicle Flap. 3. When periodontal pockets are not present. Advantages: 1. The risk of loss of alveolar bone is minimized because the interdental bone is more resistant to loss than is radicular bone. 2. The papillae usually supply a greater width of attached gingiva than from the radicular surface of a tooth. 3. The clinical predictability of this procedure is fairly good. Disadvantage: Technique sensitive—Having to join together the small flap in such a way so that they act as a single flap


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Coronally-repositioned flap Indications: • Esthetic coverage of exposed roots. • For tooth sensitivity owing to gingival recession. Advantages: • Treatment of multiple areas of root exposure. • No need for involvement of adjacent teeth. • High degree of success. • Even if the procedure does not work, it does not increase the existing problem. Disadvantage: There is a need for two surgical procedures if the zone of keratinized gingiva is inadequate


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First Technique Step 1 : Make two apically-divergent vertical releasing incisions Step 2 : A split thickness flap is prepared on coronal side and full thickness flap is prepared apical to recession Step 3 : Once the flap is reflected the root surfaces are debrided thoroughly. Some authors have suggested the use of citric acid with a pH 1.0 for conditioning the root surface. Step 4 : At the base of the inner surface of the flap, approximately 3 mm apical to the bone dehiscense, a horizontal incision is made through the periosteum, followed by a blunt dissection into the lining mucosa to release muscle tension. Now the mucosal graft can be easily positioned coronally at the level of cementoenamel junction. Step 5 : interrupted sutures and additional sling sutures can be placed to maintain the flap in place. Step 6 : Periodontal dressing is placed to protect the wound during initial healing.


Second Technique (Semilunar flap) Indication: Small localized area Advantages: • No vestibular shortening, as occurs with the coronallypositioned flap. • No esthetic compromise of interproximal papillae. • No need for sutures. Disadvantages: • Inability to treat large areas of gingival recession. • The need for a free gingival graft if there is an underlying dehiscence or fenestration.


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Subepithelial Connective Tissue Graft Indications: • Where esthetics is of prime concern • For covering multiple denuded roots • In the absence of sufficient width of attached gingiva in the adjacent areas. Advantages: • High degree of cosmetic enhancement • Incurs no additional cost for autogenous donor tissue • One step procedure • Minimal palatal trauma • Increased graft vascularity. Disadvantages: • High degree of technical skills required. • Complicated suturing


Technique I. Preparation of recipient site: The initial horizontal right angle incision is made into the adjacent interdental papillae at, or slightly coronal to the cementoenamel junction of the tooth with an exposed root surface. preserve the papillary blood supply A partial thickness flap is raised without vertical incisions SRP Root Conditioning with citric acid pH 1.0 or tetracycline HCl in a concentration of 250 mg mixed in 5 ml of sterile water approximate mesio distal width necessary for the graft is measured with a periodontal probe. II. Excision of the donor tissue 1st incision horizontal incision 2-3mm apical to gingival margin 2nd incision parallel to the long axis of the teeth, 1 to 2 mm apical to the first incision raise a full thickness periosteal connective tissue graft III. Grafting to the recipient site: With interrupted sutures


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Guided Tissue Regeneration Technique For Root Coverage Indications • Esthetic demand. • Indicated for single tooth with wide, deep localized recessions. • For areas of root sensitivity where oral hygiene is impaired. • For repair of recessions associated with failing or unesthetic class V restorations. Advantages: • Techniques does not require a secondary donor surgical site reducing postoperative discomfort. • New tissue blends evenly with the adjacent tissue, providing highly esthetic results. Disadvantages: • It is sensitive technique. • Insurance of additional cost of barrier membrane.


Technique Full thickness flap till MGJ is raised.

Partial thickness flap beyond MGJ till upto 8mm is raised

SRP

Goretex memb placement and stabilizing

Coronal positioned flap placement

after 4 weeks, membrane is removed

Modifications a. Titanium–reinforced membranes used to create the space below the membrane. b. Resorbable membranes have been used to prevent a second surgery


Operations For Removal Of Frena “A frenum is a fold of mucous membrane usually with enclosed muscle fibers, that attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying periosteum.”

Indications

To prevent:

1. The accumulation of irritants.

2. The deflection of the wall of periodontal pocket which may aggravate its severity.

3. Its interference with post-treatment healing.

4. Pocket formation.

5. Injury while brushing


Frenal attachment may be of four types

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Techniques for the Removal of the Step 1 : After anesthetizing the area, engage the frenum Step 2 : Incise along the upper surface of the hemostat, the under surface of the hemostat. Step 3 : Remove the triangular resected portion of the the fibrous connective tissue attachment to the bone. Step 4 : Make a horizontal incision to dissect and separate Step 5 : Close the wound by placing interrupted sutures.

Frenum

ing the area, engage the frenum with a hemostat.

Incise along the upper surface of the hemostat, simultaneously make a similar incision along under surface of the hemostat.

angular resected portion of the frenum along with hemostat. This exposes fibrous connective tissue attachment to the bone.

Make a horizontal incision to dissect and separate the fibers attached to the bone.

Close the wound by placing interrupted sutures.

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simultaneously make a similar incision along

frenum along with hemostat. This exposes

ached to the bone.


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Health & Medicine

036. mucogingival surgery