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periodontal plastic surgery.pptx

  2. 2. periodontal plastic surgery," a term originally proposed by Miller in 1993 and broadened to include the following areas: • periodontal-prosthetic corrections • crown lengthening • socket preservation • ridge augmentation • esthetic surgical corrections • coverage of the denuded root surface • reconstruction of papillae INTRODUCTION
  3. 3. “Periodontal plastic surgery” is defined as the surgical procedures performed to correct or eliminate anatomic, developmental or traumatic deformities of the gingiva or alveolar mucosa.
  4. 4. Objectives of periodontal plastic surgical techniques included …… (1) widening of attached gingiva, (2) deepening of shallow vestibules, (3) resection of the aberrant frena
  5. 5. The original rationale for mucogingival surgery was predicated on the assumption that a minimal width of attached gingiva was required to maintain optimal gingival health. A wide, attached gingiva is more protective against the accumulation of plaque than a narrow or a nonexistent zone. People who practice good and atraumatic oral hygiene may maintain excellent gingival health with almost no attached gingiva. Problems Associated with Attached Gingiva
  6. 6. Widening the attached gingiva accomplishes the following four objectives: 1. enhances plaque removal around the gingival margin 2. improves esthetics 3. reduces inflammation around restored teeth 4. gingival margin binds better around teeth and implants with attached gingiva.
  7. 7. Problems Associated with Shallow Vestibule ● Gingival recession displaces the gingival margin apically, thus reducing vestibular depth, which is measured from the gingival margin to the bottom of the vestibule. ● As indicated previously, with minimal vestibular depth, proper hygiene procedures are jeopardized. ● The sulcular brushing technique requires the placement of the toothbrush at the gingival margin, which may not be possible with reduced vestibular depth.
  8. 8. Problems Associated with Aberrant Frenum A frenum that encroaches on the margin of the gingiva may interfere with plaque removal, and the tension on the frenum may tend to open the sulcus. In such cases, surgical removal of the frenum is indicated
  9. 9. Techniques to Increase Attached Gingiva Gingival augmentation apical to the area of recession. A graft, either pedicle or free, is placed on a recipient bed apical to the recessed gingival margin Gingival augmentation coronal to the recession (root coverage). A graft (either pedicle or free) is placed covering the denuded root surface.
  11. 11. Free Gingival Autografts Free gingival graft are used to create a widened zone of attached gingiva The Classic Technique Step 1: Prepare the recipient site. The purpose of this step is to prepare a firm connective tissue bed to receive the graft. The recipient site can be prepared by incising at the existing mucogingival junction with a No. 15 blade to the desired depth, blending the incision on both ends with the existing mucogingival line. Periosteum should be left covering the bone A, Before treatment; minimal keratinized gingiva.
  12. 12. ● Extend the incisions to approximately twice the desired width of the attached gingiva, allowing for 50% contraction of the graft when healing is complete ● The amount of contraction depends on the extent to which the recipient site penetrates the muscle attachments. The deeper the recipient site, the greater is the tendency for the muscles to elevate the graft and reduce the final width of the attached gingiva. B, Recipient site prepared for free gingival graft.
  13. 13. ● The No. 15 blade is used to incise along the gingival margin to separate a flap consisting of epithelium and underlying connective tissue without disturbing the periosteum ● Extend the flap to the depth of the vertical incisions. ● Suture the flap where the apical portion of the free graft will be located. Three to four independent gut sutures are placed. The needle is first passed as a superficial mattress suture perpendicular to the incision and then on the periosteum parallel to the incision.
  14. 14. ● Grafts can also be placed directly on bone tissue. For this technique, the flap should be separated by blunt dissection with a periosteal elevator ● ADVANTAGES Less swelling Better haemostasis Less shrinkage Less post operative mobility
  15. 15. Step 2: Obtain the graft from the donor site ● transferring a piece of keratinized gingiva approximately the size of the recipient site ● a partial-thickness graft is used. The palate is the usual site from which the donor tissue is removed. ● The graft should consist of epithelium and a thin layer of underlying connective tissue. C, Palate will be donor site
  16. 16. ● Place the template over the donor site, and make a shallow incision around it with a No. 15 blade. ● Insert the blade to the desired thickness at one edge of the graft. ● Elevate the edge and hold it with tissue forceps. ● Proper thickness is important for survival of the graft. It should be thin enough to permit diffusion of fluid from the recipient site ● A graft that is too thin may necrose and expose the recipient site. ● If the graft is too thick, its peripheral layer is jeopardized because of the excessive tissue that separates it from new circulation and nutrients.
  17. 17. ● Thick grafts may also create a deeper wound at the donor site, with the possibility of injuring major palatal arteries. ● The ideal thickness of a graft is between 1.0 and 1.5 mm. ● After the graft is separated, remove the loose tissue tags from the undersurface. ● Thin the edge to avoid bulbous marginal and interdental contours.
  18. 18. Step 3:Transfer And Immobilize The Graft ● Remove The sponge from the recipient site, re apply it with pressure if necessary until bleeding is stopped. Remove the excess clot.A thick clot interferes with vascularisation of the graft. ● Position the graft and adapt it firmly to the recipient site. A space between the graft and the underlying tissue (dead space) impairs vascularization and jeopardizes the graft. ● Suture the graft at the lateral borders and to the periosteum to secure it in position. The graft must be immobilized. Any movement interferes with healing. E, Graft transferred to recipient site.
  19. 19. ● Cover the donor site with a periodontal pack for 1 week and repeat if necessary. Retention of the pack on the donor site can be a problem. ● If facial attached gingiva was used, the pack may be retained by locking it through the interproximal spaces onto the lingual surface. ● If there are no open interdental spaces, the pack can be covered by a plastic stent wired to the teeth. ● A modified Hawley retainer is useful to cover the pack on the palate and over edentulous ridges. Step 4: Protect the donor site.
  20. 20. Healing of the Graft ● The success of the graft depends on survival of the connective tissue. ● Fibrous organization of the interface between the graft and the recipient bed occurs within two to several days. ● The graft is initially maintained by a diffusion of fluid from the host bed, adjacent gingiva, and alveolar mucosa. ● The fluid is a transudate from the host vessels and provides nutrition and hydration essential for the initial survival of the transplanted tissue ● During the first day, the connective tissue becomes edematous and disorganized and undergoes degeneration and lysis of some of its elements. ● As healing progresses, the edema is resolved and degenerated connective tissue is replaced by new granulation tissue.
  21. 21. ● Revascularization of the graft starts by the second or third day. ● Many of the graft vessels degenerate and are replaced by new ones, and some of these participate in the new circulation. ● The central section of the surface is the last to vascular- ize, but this is complete by the tenth day ● The epithelium undergoes degeneration and sloughing, with complete necrosis occurring in some areas. ● It is replaced by epithelium from the borders of the recipient site.
  22. 22. ● A thin layer of new epithelium is present by the fourth day, with rete pegs developing by the seventh day. ● healing of a graft of intermediate thickness (0.75 mm) is complete by 10 weeks; thicker grafts (1.75 mm) may require 16 weeks or longer. ● Functional integration of the graft occurs by the 17th day, but the graft is morphologically distinguishable from the surrounding tissue for months
  23. 23. Free Connective Tissue Autografts ● It is based on the fact that the connective tissue carries the genetic message for the overlying epithelium to become keratinized. Therefore only connective tissue from beneath a keratinized zone can be used as a graft. ● The advantage of this technique is that the donor tissue is obtained from the undersurface of the palatal flap, which is sutured back in primary closure, therefore healing is by first intention. The patient has less discomfort postoperatively at the donor site
  24. 24. ● Another advantage of the free connective tissue autograft is that, improved esthetics can be achieved because of a better color match of the grafted tissue to the adjacent areas. A,Lack of keratinized, attached gingiva buccal to central incisor .B,Verticalincisionstopreparerecipient site .B,Vertical incisions to prepare recipient site
  25. 25. C, Recipient site prepared. D, Palate from which connective tissue will be removed for donor tissue.
  26. 26. E, Removal of connective tissue . F, Donor site sutured
  27. 27. . G, Connective tissue for graft. H, Free connective tissue placed at donor site.
  28. 28. I, Postoperative healing at 10 days. J, Final healing at 3 months.
  29. 29. Apically Displaced Flap ● This technique uses the apically positioned flap, either partial thickness or full thickness, to increase the zone of keratinized gingiva. ● The apically displaced flap technique increases the width of the keratinized gingiva but cannot predictably deepen the vestibule with attached gingiva. ● Adequate vestibular depth must be present before the surgery to allow apical positioning of the flap
  30. 30. Accomplishments. ● The apically displaced flap technique increases the width of the keratinized gingiva but cannot predictably deepen the vestibule with attached gingiva. ● The edge of the flap may be located in three positions in relation to the bone as follow 1. Slightly coronal to the crest of the bone. 2. At the level of the crest. 3. Two millimeters short of the crest
  31. 31. Gingival Augmentation Coronal to Recession (Root Coverage) classification of recession proposed by Miller… Class I. Marginal tissue recession 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 extends to or beyond the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be subclassified into wide and narrow. Class III. Marginal tissue recession extends to or beyond the mucogingival junction. There is bone and soft tissue loss interdentally or malpositioning of the tooth. Class IV Marginal tissue recession extends to or beyond the mucogingival Junction. There is severe bone and soft tissue loss interdentally or severe tooth malposition.
  32. 32. The following is a list of techniques used for root coverage. gingival autograft 2.pedicle graft (laterally or horizontally displaced flap) 3.coronally advanced flap; includes semilunar pedicle graft (Tarnow) 4.subepithelial connective tissue graft (Langer) 5.guided tissue regeneration (GTR) 6.pouch and tunnel technique (coronally advanced tunnel technique)
  33. 33. Free Gingival Autograft The Classic Technique. Miller applied the classic free gingival autograft described previously with a few modifications. Step 1: Root planing. Root planing is performed with the application of saturated citric acid for 5 minutes on the root surface.
  34. 34. Step 2: Prepare the recipient site. Make a horizontal incision in the interdental papillae at right angles to create a margin against which the graft may have a butt joint with the incision. Vertical incisions are made at the proximal line angles of adjacent teeth and the retracted tissue is excised. Maintain an intact periosteum in the apical area Step 3 : similar to the classic technique described earlier…
  35. 35. Pedicle Autograft Laterally (Horizontally) Displaced Pedicle Flap. The laterally positioned flap can be used to cover isolated, denuded root surfaces that have adequate donor tissue laterally. The following is a step-by-step surgical description : Step 1: Prepare the recipient site Epithelium is removed around the denuded root surface. The exposed connective tissue will be the recipient site for the laterally displaced flap. A, Preoperative view, maxillary bicuspid.
  36. 36. Step 2: Prepare the flap. The periodontium of the donor site should have a satisfactory width of attached gingiva and minimal loss of bone, without dehiscence or fenestration. A full-thickness or partial-thickness flap may be used. With a No. 15 blade, make a vertical incision from the gingival margin to outline a flap adjacent to the recipient site. Incise to the periosteum, and extend the incision into the oral mucosa to the level of the base of the recipient site. B, Recipient site is prepared by exposing the connective tissue around the recession.
  37. 37. The flap should be sufficiently wider than the recipient site to cover the root and provide a broad margin for attachment to the connective tissue border around the root. C, Incisions are made at the donor site in preparation of moving the tissue laterally.
  38. 38. Step 3: Transfer the flap. Slide the flap laterally onto the adjacent root; making sure that it lies flat and firm without excess tension on the base. Fix the flap to the adjacent gingiva and alveolar mucosa with interrupted sutures . D, Pedicle flap is sutured in position.
  39. 39. Step 4: Protect the flap and donor site. Cover the operative field with aluminum foil and a soft periodontal dressing, extend- ing it interdentally and onto the lingual surface to secure it. Remove the dressing and sutures after 1 week. E, Post- operative result at 1 year.
  40. 40. Coronally Advanced Flap. The purpose of the coronally displaced flap procedure is to create a split-thickness flap in the area apical to the denuded root and position it coronally to cover the root. Classic Technique Step 1. With two vertical incisions, delineate the flap. These incisions should go beyond the mucogingival junction. Make a crevicular incision from the gingival margin to the bottom of the sulcus. Elevate a mucoperiosteal flap using careful sharp dissection. A, Preoperative view. Note the recession and the lack of attached gingiva.
  41. 41. Step 2. Scale and plane the root surface. Step 3. Return the flap and suture it at a level coronal to the pretreatment position. Cover the area with a periodontal dressing, which is removed along with the sutures after 1 week. B, After placement of a free gingival graft.
  42. 42. C, Three months after placement of the graft. D, Flap, including the graft, positioned co and sutured. E, Six months later.
  43. 43. Semilunar Flap Technique Tarnow has described the semilunar coronally repositioned flap to cover isolated denuded root surfaces. Step 1. A semilunar incision is made following the curvature of the receded gingival margin and ending about 2- 3 mm short of the tip of the papillae. A, Class 1 recession on the facial surface of the maxillary right central incisor.
  44. 44. Step 2. Perform a split-thickness dissection coronally from the incision and connect it to an intrasulcular incision. Step 3. The tissue will collapse coronally, covering the denuded root. It is then held in its new position for a few minutes with moist gauze. Many cases do not require either sutures or periodontal dressing. This technique is simple and predictably provides 2- 3 mm of root coverage. B, A semilunar incision is made and tissue separated from the underlying bone.
  45. 45. This technique is indicated where the recession is not extensive (3 mm) and the facial gingival biotype is thick. It is successful for the maxilla, particularly in covering roots left exposed by the gingival margin receding from a recently placed crown margin. It is not recommended for the mandibular dentition. C, Crevicular incision.
  46. 46. D, The flap collapses covering the incision, no sutures given. E, Appearance after 7 weeks showing complete root coverage.
  47. 47. Subepithelial Connective Tissue Graft (Langer and Langer) The subepithelial connective tissue procedure is indicated for larger and multiple defects with good vestibular depth and gingival thickness to allow a split- thickness flap to be elevated. Adjacent to the denuded root surface, the donor connective tissue is sandwiched between the split flap. A, Preoperative view: recession on mandibular 1st premolar,
  48. 48. Step 1. Raise a partial-thickness flap with a horizontal incision 2 mm away from the tip of the papilla and two vertical incisions 1- 2 mm away from the gingival margin of the adjoining teeth. These incisions should extend at least one tooth wider mesiodistally than the area of gingival recession. Extend the flap to the mucobuccal fold. B, Graft site prepared,
  49. 49. Step 2. Thoroughly plane the root, reducing its convexity. Step 3. Obtain a connective tissue graft from the palate by means of a horizontal incision 5- 6 mm from the gingival margin of molars and premolars. The palatal wound is sutured in a primary closure. C, Graft placed on the recipient site.
  50. 50. Step 4. Place the connective tissue on the denuded root(s). Suture it with resorbable sutures to the periosteum. Step 5. Cover the graft with the outer portion of the partial- thickness flap and suture it interdentally. D, Flap replaced and covered over the graft.
  51. 51. Step 6. Cover the area with dry foil and surgical dressing. After 7 days, the dressing and sutures are removed. The esthetic results are favorable with this technique since the donor tissue is connective tissue. The donor site heals by primary intention. E, Postoperative view showing complete root coverage.
  52. 52. Guided Tissue Regeneration Technique for Root Coverage GTR should result in the reconstruction of the attachment apparatus, along with cover- age of the denuded root surface. The following is a step-by-step description of the surgery A, Marked recession of maxillary left cuspid.
  53. 53. Step 1. A full-thickness flap is reflected to the mucogingival junction, continuing as a partial-thickness flap 8 mm apical to the mucogingival junction. Step 2. A membrane is placed over the denuded root surface and the adjacent tissue. B, Vertical incisions made and membrane placed over recession
  54. 54. Step 3. A suture is passed through the portion of the mem- brane that will cover the bone. This suture is knotted on the exterior and tied to bend the membrane, creating a space between the root and the membrane. This space allows for the growth of tissue beneath the membrane. . C, Flap sutured over the membrane.
  55. 55. Step 4. The flap is then positioned coronally and sutured. Four weeks later, a small envelope flap is performed, and the membrane is carefully removed. The flap is then again positioned coronally, to protect the growing tissue, and sutured. One week later these sutures are removed D, Postoperative result. Note complete coverage of recession.
  56. 56. ● Membranes used are Titanium - reinforced membrane Resorbable membrane ● GTR technique is better when the recession is greater than 4.8mm apicoronally.
  57. 57. Pouch and Tunnel Technique (Coronally Advanced Tunnel Technique) To minimize incisions and the reflection of flaps and to provide abundant blood supply to the donor tissue, the placement of the subepithelial donor connective tissue into pouches beneath papillary tunnels allows for intimate contact of donor tissue to the recipient site
  58. 58. Effective for the anterior maxillary area in which vestibular depth is adequate and there is good gingival thickness. Advantage : Thickening of the gingival margin after healing. The thicker gingival margin is stable to allow for the possibility of "creeping reattachment" of the margin. The use of small, contoured blades enables the surgeon to incise and split the gingival tissues to create the recipient pouches and tunnels.
  59. 59. Step 1. Preparation of the patient includes plaque control instruction and careful scaling and root planing several weeks before the surgical procedure. The patient is instructed to rinse for 3.0 s with chlorhexidine gluconate solution 0.12%. Step 2. After adequate anesthesia of the region, the surgical procedure, as follows, is performed.
  60. 60. Step 3. Composite material stops are placed at the contact points (temporary) to prevent the collapse of the suspended sutures into the interproximal spaces before the surgery Step 4. Root planing of the exposed root surfaces is performed using Gracey curettes. A, Preoperative view. Note gingival recession.
  61. 61. Step 5. Initial sulcular incisions are made using 15c and 12d blades. Small, contoured blades (Fig. 50.17) and mini curettes are used to create the recipient pouches and tunnels. Step 6. On the buccal aspect, an intrasulcular incision is made around the necks of the teeth. The incision is extended to one adjacent tooth both mesially and distally using a 15c blade B, Sulcular incision is made from the mesial to the facial line angles.
  62. 62. Step 7. Muscle fibers and any remaining collagen fibers on the inner aspect of the flap, which prevent the buccal gingiva from being moved coronally, are cut using Gracey curettes. Step 8. The papillae are kept intact and undermined to maintain their integrity and carefully released from the underlying bone
  63. 63. Step 9. An envelope, full-thickness pouch and tunnel are created and extended apically beyond the mucogingival line by blunt dissection for the insertion of the free connective tissue graft through the intrasulcular incision. Step 10. The size of the pouch, which includes the area of the denuded root surface, is measured so that an equivalent size donor connective tissue can be procured from the tuberosity C, A tunnel is made through the papilla using a blunt incision.
  64. 64. E, The connective tissue is placed through the papillary tunnel and apically beneath the pouch.
  65. 65. Step 11. A second surgical site is created to obtain a connective tissue graft of adequate size and shape to be placed at the recipient site. Step 12. A mattress suture placed at one end of the graft is helpful in guiding the graft through the sulcus and beneath each interdental papilla. The border of the tissue is gently pushed into the pouch and tunnel using tissue forceps and a packing instrument. D, A connective tissue graft is taken from the palate.
  66. 66. Step 13. A mattress suture placed on one end of the graft will help maintain the graft in position while the buccal tissue covers the connective tissue graft. This connective tissue graft is anchored to the inner aspect of the buccal flap in the interdental papilla area. A vertical mattress suture is used to hold the connective tissue in position beneath the gingiva. F, The facial gingival margin covers the connective tissue using horizontal mattress sutures interdentally.
  67. 67. G, Postoperative view. Note complete root coverage and thickened gingival margin at 3 months.
  68. 68. Techniques to Remove the Frenum ● 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. ● A frenum becomes a problem if the attachment is too close to the marginal gingiva. Tension on the frenum may pull the gingival margin away from the tooth. ● This condition may be conducive to plaque accumulation and inhibit proper placement of the toothbrush at the gingival margin
  69. 69. FRENECTOMY Frenectomy is complete removal of the frenum, including its attachment to underlying bone and may be required in the correction of an abnormal diastema between the maxillary central incisors. FRENOTOMY Frenotomy is the relocation of the frenum, usually in a more apical position.
  70. 70. Step 1. After anesthetizing the area, engage the frenum with a hemostat inserted to the depth of the vestibule. Step 2. Incise along the upper surface of the hemostat, extending beyond the tip. A, Preoperative view of frenum between the two maxillary central incisors.
  71. 71. Step 3. Make a similar incision along the undersurface of the hemostat. Step 4. Remove the triangular resected portion of the frenum with the hemostat. This exposes the underlying fibrous attachment to the bone.
  72. 72. Step 5. Make a horizontal incision, separating the fibers and bluntly dissect to the bone. Step 6. If necessary, extend the incisions laterally and suture the labial mucosa to the apical periosteum. A gingival graft or connective tissue graft is placed over the wound. B, Removal of the frenum from both the lip and gingiva.
  73. 73. Step 7. Clean the surgical field with gauze sponges until bleeding stops. Step 8. Cover the area with dry aluminum foil and apply the periodontal dressing. C, Site is sutured after it is placed over the wound.
  74. 74. Step 9. Remove the dressing after 2 weeks and redress if necessary. One month is usually required for the formation of an intact mucosa with the frenum attached in its new position. D, Postoperative view at 2 weeks
  75. 75. Techniques to Deepen the Vestibule ● The presence of adequate vestibular depth is important for both oral hygiene and retention of prosthetic appliances. ● The classic clinical studies in the early 1960s by Bohannan indicated that deepening of the vestibule not involving use of a free gingival graft were not successful when evaluated years later.
  76. 76. ● Predictable deepening of the vestibule can only be accomplished by the use of free autogenous graft techniques and their variants, ● The important clinical aspect in deepening the vestibule is the proper preparation of the recipient site. ● The recipient site must be covered by immobile periosteal tissue. ● If there is a lack of periosteal connective tissue, the donor tissue may be placed over bone. ● The donor tissue may be either free gingival or connective tissue, but it must be placed over a nonmobile recipient site.
  77. 77. Conclusion….. ● periodontal plastic surgery refers to soft-tissue relationships and manipulations. In all of these procedures, blood supply is the most significant concern. ● A major complicating factor is the avascular root surface and many modifications to existing techniques are used to overcome this. ● Diffusion of fluids is short term and of limited benefit as tissue size increases. ● Thus the formation of a circulation through anastomosis and angiogenesis is crucial to the survival of these therapeutic procedures.
  78. 78. ● The formation of vascularity is based on growth molecules, such as vascular endothelial growth factor (VEGF) and cellular migration, proliferation, and differentiation. ● As tissue- engineering techniques improve, the success and predict- ability of mucogingival surgery should dramatically increase.
  79. 79. REFERENCES American Academy of Periodontology: American Academy of Periodontology: glossary of periodontal terms, ed 3, Chicago, 1992, American Academy of Periodontology. Azzi R, Takei H, Etienne D, et al: Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts, Int] Peria Rest Dent 2141- 147, 2001. Becker BE, Becker W: Use of connective tissue autografts for treatment of mucogingival problems, Int] Periodont Restor Dent 6:89, 1986. Carranza FA Jr, Carraro JJ: Mucogingival techniques in periodontal surgery, JPa iodontol 41:294, 1970. Cortellini P, Clauser C, Pini-Prato GP: Histologic assessment of new attach- ment following the treatment of a human buccal recession by means of a guided tissue regeneration procedure,] Periodontol 64:387, 1993. .