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Periodontal Plastic Surgery Techniques
- 1. Periodontal Plastic and Esthetic Surgery PART -1 GUIDED BY : DR AMIT GOEL DR DIVYA JAGGI PRESENTED BY : DR MALVIKA THAKUR PG III YEAR
- 2. CONTENTS 1. Introduction 2. General considerations 3. Tissue barrier concept 4. Problems associated with attached gingiva 5. Gingival augmentation procedures Techniques for increasing attached gingiva Root coverage procedures 6. Techniques for increasing attached gingiva 7. Conclusion
- 3. INTRODUCTION MUCOGINGIVAL SURGERY Nathan Friedman, 1957 PERIODONTAL PLASTIC SURGERY Miller, 1993 World Workshop in Clinical Periodontics 1996 MUCOGINGIVAL SURGERY Surgical procedures designed to preserve gingiva, remove abberant frenum, or muscle attachments, and increase the depth of vestibule. Periodontal plastic surgery: Surgical procedures performed to prevent or correct anatomical, developmental, traumatic or plaque induced defects of the gingiva, alveolar mucosa or bone. [Proceedings of the world workshop in Periodontics 1996] 1/25 MUCOGINGIVAL THERAPY: A Broader term Periodontal treatment involving procedures for correction of defects in morphology, position and/or amount of soft tissue and underlying bone support at teeth and implants. [GPT 2001] Gingival augmentation Coverage of the denuded root surface Crown lengthening Periodontal prosthetic corrections Reconstruction of the papillae Ridge augmentation Esthetic surgical corrections Esthetic surgical correction around implants Surgical exposure of unerupted teeth for orthodontics Lip repositioning Periodontal plastic surgery - broadened to include following areas
- 4. General considerations Existing keratinized gingiva should always be maintained. Exposing bone to increase the zone of keratinized gingiva is contraindicated (Wilderman, 1964). When an adequate zone of attached keratinized gingiva exists, vestibular depth is not a factor (Bohannan, 1963). PRINCIPLES OBJECTIVES 1.Adequate zone of attached keratinized gingiva. 2. Eliminate muscle and frenulum pull 3. Deepen the vestibule 4. Eliminate pockets that extend beyond the mucogingival line 5. Cover denuded root surfaces for aesthetics or hypersensitivity 6. Overcome the anatomic factors of tooth position like thin alveolar housing 7. Minimize recession during orthodontic movement 8. Overcome the trauma of restorative dentistry needing subgingival placement 9. Stabilize and maintain a healthy mucogingival complex 10.Correct areas of progressive gingival recession 11.Correct ridge deformities and undercuts 2/25
- 5. Tissue barrier concept Goldman and Cohen (1979) Dense collagenous band of connective tissue - retards or obstructs the spread of inflammation better than does the loose fibre arrangement of the alveolar mucosa. ↑ng the zone of Attached Gingiva - Adequate tissue barrier. Hall(1977) - critical factors to be considered other than lack of adequate zone of attached gingiva. Waerhaug (1971), Wennström et al (1981, 1982), Kure et al (1985) Kennedy et al (1985), Lindhe et al (1973), Baker & Seymour (1976), Rubin (1979), & Lindhe & Nyman(1980) 3/25
- 6. Problems associated with attached gingiva Mucogingival surgery : create/↑ the width of AG. Narrow zone of gingiva (Friedman 1957; Ochsenbein 1960). Inadequate zone of gingiva (Friedman, 1962) (Stern, 1976). Narrow gingiva + Shallow vestibular fornix (Gottsegen 1954; Rosenberg 1960; Corn 1962; Carranza & Carraro 1970). What could be regarded as being an “adequate” or “sufficient”dimension of the gingiva? No minimal width of attached gingiva has been established as the standard necessary for gingival health. VARIOUS AUTHORS ADEQUATE ATTACHED GINGIVA Corn, 1962 > 3mm (Keratinized gingiva) Bowers, 1963 <1 mm Friedman, 1962; De Trey & Bernimoulin, 1980 Gingiva that is compatible to gingival health & prevents retraction of gingival margin during movement of alv. mucosa. Lang & Loe, 1972 2mm KG Grevers 1977, Miyasato et al., 1977 Min KG = 1mm, Appreciable KG = 2mm Maynard and Wilson, 1979 2mm FG + 3mm AG = 5mm KG Dorfman et al. (1980). Min. zone of gingiva may not compromise periodontal health Further support for the conclusion that a minimal zone of gingiva may not compromise periodontal health is available from a number of other longitudinal clinical studies (e.g. De Trey & Bernimoulin 1980; Hangorsky & Bissada 1980; Lindhe & Nyman 1980; Schoo & van der Velden 1985; Kisch et al. 1986; Wennström 1987; Freedman et al. 1999). 4/25
- 7. Gingival augmentation apical to recession Free gingival autograft Free connective tissue autograft Apically positioned flap Gingival augmentation coronal to recession (root coverage) Pedicle soft tissue graft procedures Free soft tissue graft procedures TECHNIQUES FOR INCREASING ATTACHED GINGIVA Indications for gingival augmentation • Presence of a narrow zone of gingiva per se cannot justify surgical intervention. (Proceedings of the 1st European Workshop on Periodontology 1994, Proceedings of the World Workshop on Periodontics, 1996). • The patient experiences discomfort during toothbrushing and/or chewing due to an interfering lining mucosa. • When orthodontic tooth movement is planned and the final positioning of the tooth can be expected to result in an alveolar bone dehiscence. • When subgingival restorations are placed in areas with a thin marginal tissue. 5/25
- 8. 1.Free gingival autograft Introduced by Bjorn, 1963 Nabers introduced the term “Free gingival graft”, 1966 Described by Sullivan & Atkins, 1968. Techniques: 1. Classical Technique 2. Variant atechniques : I. Connective Tissue Technique (Edel 1974) II. Accordian technique (Rateitschak et al 1985) III. Strip technique (Han et al 1993) INDICATIONS To ↑ the width of AG. To form new functional AG when AG is completely lacking For pedicle gingival graft when gingiva of the adjacent teeth is insufficient as donor site. To remove abnormal frenum and attachment. To deepen the vestibule To cover exposed roots. For ridge augmentation procedures. (Ref- Periodontal Surgery, A clinical Atlas, Naoshi Sato) ADVANTAGES 1. High degree of predictability 2. Simplicity 3. Ability to treat multiple teeth at the same time 4. Can be performed when keratinized gingiva adjacent to the involved area is insufficient 5. As the first step in a two-stage procedure for attaining root coverage 6. As a single step for attaining root coverage. DISADVANTAGES 1.Two operative sites 2. Compromised blood supply 3. Lack of predictability in attempting root coverage 4. Greater discomfort 5. Poor hemostasis 6. Retention of graft 6/25
- 9. 1894,Pierre Fauchard - "The Surgeon Dentist." 1963, Björn - free transplantation of gingiva propria. 1964, Seibert - palatal mucosa was transplanted to the labial gingival surface. 1965, Cowan - use of mucosal grafts to deepen the sulcus. 1966, Nabers, Transplanted Mx AG to Mnd ant region to create an ↑ zone of AG. Historical background of Free grafts: 1966, Haggerty,Used FGG to create a healthy environment for full crown preparation. 1967, Becker, FGG in restoring adequacy to a narrow dentogingival junction + use of a presuturing technique. 1967, Gargiulo and Arrocha,Described the early healing phases of the free gingival grafts 1967,Gargiulo and Arrocha used gingivectomy tissue as donor tissue. 1968, Sullivan and Atkins, Use of FGG in treating areas of gingival recession. 1968, Oliver et al presented healing studies about free gingival grafts in dogs. 1969, Staffileno and Levy reported that the success of the graft depends upon the survival of the connective tissue. 1972,1974, Karring & colleagues showed that CT determines the nature of graft tissue and described the use of CT autografts 1974, Ellegaarde and colleagues used FGG to retard epithelial migration over osseous grafts. 1976, Dordick and colleagues placed grafts directly on bone for a firmer attachment 7/25
- 10. • Graft thickness was originally outlined by Sullivan and Atkins in 1968. • Thin or intermediate thickness grafts: Increasing zone of keratinized tissue (Soehren et al 1970). • Thick or full thickness grafts: Root coverage and ridge augmentation procedures 8/25
- 14. MODIFICATION OF THE RECIPIENT BED 10/25
- 15. 2. Accordion technique Rateitschak et al, 1985 Expansion of the graft by alternate incisions in opposite sides of the graft. It increases the donor graft tissue by changing the configuration of the tissue. 11/25
- 16. 3. STRIP TECHNIQUE FOR FGG Han et al
- 17. Reasons for graft failure: 1. Area of exposed root surface 2. Close graft adaptation 3. Residual fatty/ glandular tissue 4. Movement of graft 12/25
- 18. Healing of free soft tissue grafts Oliver et al 1968 and Nobuto et al 1988 - Studied In Monkeys 13/25 PHASE HEALING INITIAL PHASE (0-3 DAYS) • Thin layer of exudate b/w graft & recipient bed. •Avascular plasmatic circulation (Forman 1960; Reese & Stark 1961) • Epithelium of free graft gets desquamated REVASCUL ARI- SATION (2-11 DAYS) • Anastomosis b/w graft & recipient site blood vessels. • Capillaries proliferate in the graft tissue • Fibrous union b/w graft & conn tissue bed • Re epithelialization of the grafT TISSUE MATURATI ON (11-42 DAYS) • ↓ in the number of blood vessels to normal by the 14th day. • Epithelium maturation- formation of keratin layer • Functional integration – by 17th day • Morphologically distinguishable for several months.
- 19. 2. FREE CONNECTIVE TISSUE AUTOGRAFT Originally advocated by Alan Edel, 1974 Based on the concept that “CT carries the genetic message for the overlying epithelium to become keratinized” (Janson W A et al 1969) FGG limitations: volume augmentation and aesthetic result - advantages of using CTG are evident in the literature (B. Langer & Calagna 1980; B. Langer & L. Langer 1985). ADVANTAGES: Donor tissue - undersurface of the palatal flap - primary closure - healing is by first intention. Patient has less discomfort postoperatively at the donor site. Improved esthetics can be achieved because of a better color match of the grafted tissue to the adjacent areas. 14/25
- 20. Classification of grafts from palate Liu classification (2002) Class I: One incision line Class II: Two incision lines (L Shape) Class III: Three incision lines (U shape) Subclassification (horizontal incision) Type A: one horizontal incision Type B: two horizontal incisions 15/25
- 21. Trap door technique – Edel.A 1974 16/25
- 22. PARALLEL INCISION METHOD - Burton Langer and Laureen Langer 1985 17/25
- 23. John F. Bruno technique (1994) 18/25
- 24. THE SINGLE-INCISION FECHNIQUE Hurzeler 1999 - Suggested a single incision technique to harvest SCTG 19/25
- 26. FREE CONNECTIVE TISSUE AUTOGRAFTS TO INCREASE ATTACHED GINGIVA 20/25
- 27. 3.Apically positioned flap Nabers (1954) - “Repositioning of the attached gingiva”. Ariaudo and Tyrrell (1957) - Modified Nabers procedure. Friedman (1962) - “Apically repositioned flap”. Friedman: Beveled flap (for treating pockets on the palatal side) Buccal surfaces only ADVANTAGES • Eliminates periodontal pocket • Preserves attached gingiva • Establish gingival morphology facilitating good hygiene DISADVANTAGES • Esthetics problem • Cause attachment loss due to surgery • Hypersensitivity • Risk of root caries 21/25 INDICATIONS • To eliminate periodontal pocket • To increase the width of attached gingiva • To lengthen the clinical crown • To improve gingival and bone morphology CONTRAINDICATIONS • Where esthetics is critical • Deep intrabony pockets • High risks of caries • Severe hypersensitivity • Marked mobility
- 28. Friedman (1964) 1. Class I: KG is more than adequate; use of a labial or buccal incision placed 1 to 3 mm from the crest of the gingiva 2. Class II: KG is adequate; use of crestal incision; the flap is apically positioned to the crest of bone 3. Class III: KG is inadequate; use of sulcular incision; the flap is apically positioned 1 to 2 mm below the crest of bone to increase the zone of KG. 22/25 The edge of the flap may be located in 3 positions in relation to the bone: Slightly coronal to the crest of the bone • Preserve the attachment of supracrestal fibers. • Result in: • Thick gingival margins and interdental papillae • Deep sulci with the risk of recurrent pockets At the level of the crest • Satisfactory gingival contour, provided that the flap is adequately thinned 2mm short of the crest • Produces the most desirable (a firm, tapered gingival margin) gingival contour and the same post- treatment level of gingival attachment as obtained by placing the flap at the crest of the bone.
- 30. MODIFIED APICALLY REPOSITIONED FLAP Carnio and Miller (1999) 24/25
- 31. Variant of MARF to Increase the Dimensions of Attached Gingiva - Carnio and Camargo (2006) 25/25
- 33. Ques: In 1996, world workshop in clinical periodontics renamed mucogingival surgery as?
- 34. Ques: What is the difference between the terms Mucogingival Therapy and Periodontal Plastic Surgery?
- 35. Ques. What are the 3 main principles of Mucogingival Surgery?
- 36. Ques. What are the objectives of Mucogingival Surgery? (List Any 5)
- 37. Ques : What is the tissue barrier concept?
- 38. Ques. What are the functions of attached gingiva ?
- 39. Ques: What are the 3 main techniques for gingival augmentation apical to recession?
- 40. Ques: What is the ideal thickness of free gingival graft?
- 41. Ques: What are the variant techniques of the free gingival graft?
- 42. Ques: Free gingival grafts with Thin or intermediate thickness are used for?
- 43. Ques. When is healing of an intermediate thickness (0.75 mm) free gingival graft complete ?
- 44. Ques: When is healing of a Thick free gingival graft (1.75 mm) complete?
- 45. Ques: Thick or full thickness Free gingival grafts are used for?
- 46. Ques: What is the width of Free gingival Graft used in Strip Technique?
- 47. Ques: What are the advantages of using Free connective tissue autograft?
- 48. Ques: What are the indications of An Apically positioned Flap?
- 49. Ques: Which are the first,second and third incisions given during Apically positioned flap?
- 50. To Be Continued …..
Editor's Notes
- Mucogingival therapy is a broader term that includes nonsurgical procedures such as papilla reconstruction by means of orthodontic or restorative therapy. Mucogingival surgery: Introduced by Nathan Friedman (1957). Surgical procedures designed to preserve gingiva, remove abberant frenum, or muscle attachments, and increase the depth of vestibule. Correction of relationships between the gingiva and the OMM with reference to 3 problems: Attached gingiva Shallow vestibule Frenum interfering with the marginal gingiva Frequently, however, this term was used to describe certain pocket elimination approaches. Therefore, in 1993, Miller (132) introduced the term ‘periodontal plastic surgery’, Accepted by the international scientific community in 1996, which was defined as ‘surgical procedures performed to prevent or correct anatomic, developmental, traumatic or disease-induced defects of the gingiva, alveolar mucosa or bone’ 1996, World Workshop in Clinical Periodontics renamed mucogingival surgery as “periodontal plastic surgery,” Among treatment procedures that may fall within this definition are various soft and hard tissue procedures aimed at:
- The ultimate goal of mucogingival surgical procedures is to create/ increase the width of attached gingiva around teeth and implants For many years the prevailing concept was that a narrow zone of gingiva was insufficient (1) to protect the periodontium from injury caused by friction forces encountered during mastication and (2) to dissipate the pull on the gingival margin created by the muscles of the adjacent alveolar mucosa (Friedman 1957; Ochsenbein 1960). “Inadequate” zone of gingiva would (1) facilitate subgingival plaque formation because of the improper pocket closure resulting from the movability of the marginal tissue (Friedman 1962) and (2) favor attachment loss and soft tissue recession because of less tissue resistance to apical spread of plaque‐associated gingival lesions (Stern 1976; Ruben 1979). Narrow gingiva + a shallow vestibular fornix might (1) favor the accumulation of food particles during mastication and (2) impede proper oral hygiene measures (Gottsegen 1954; Rosenberg 1960; Corn 1962; Carranza & Carraro 1970). The opinions expressed concerning what could be regarded as being an “adequate” or “sufficient” dimension of the gingiva varied. While some authors suggested that <1 mm of gingiva may be sufficient (Bowers 1963), others claimed that the apicocoronal height of keratinized tissue ought to exceed 3 mm (Corn 1962). A third category of authors had a more biologic approach to the question and stated that an adequate amount of gingiva is any dimension that (1) is compatible with gingival health or (2) prevents retraction of the gingival margin during movements of the alveolar mucosa (Friedman 1962; De Trey & Bernimoulin 1980). One of the first studies in which attempts were made to evaluate the significance of the gingival zone for the maintenance of periodontal health was carried out by Lang and Löe (1972) on dental students who had their teeth professionally cleaned once a day for 6 weeks. All buccal and lingual sites were examined for plaque, gingival conditions, and apicocoronal height of the gingiva. The results showed that despite the fact that the tooth surfaces were free from plaque, all sites with <2 mm of gingiva exhibited persisting clinical signs of inflammation. Based on this observation, the authors suggested that 2 mm of gingiva is an adequate width for maintaining gingival health. Subsequent clinical trials (Grevers 1977; Miyasato et al. 1977), however, failed to substantiate this concept of a required minimum dimension of gingiva. In fact, these clinical trials demonstrated that it is possible to maintain clinically healthy marginal tissues even in areas with <1 mm of gingiva. The question whether a firmly attached portion of gingiva is critical for the protection of the periodontium proper was addressed by Wennström and Lindhe (1983a, b) utilizing the Beagle dog model. CONCLUSION : Gingival health can be maintained independent of its dimensions. Furthermore, there is evidence from both experimental and clinical studies that, in the presence of plaque, areas with a narrow zone of gingiva possess a similar degree of “resistance” to continuous attachment loss as areas with a wide zone of gingiva. Hence, the traditional dogma of the need for an “adequate” width (in millimeters) of gingiva, or an attached portion of gingiva, for prevention of attachment loss is not scientifically supported. It was concluded that the mucogingival junction remains at a probably genetically predetermined location while the teeth move in an occlusal direction through adult life. In the absence of concurrent retraction of the gingival margin this results in an increase of the width of attached gingiva with advancing age.
- However, gingival augmentation should be considered in situations where, for example The earliest documented surgical techniques were: Push-back technique by Robinson and Fox 1953, Vestibular extension technique designed by Bohannan in 1962 The apically repositioned flap (APF) by Freidman in 1962 Free autogenous gingival grafts by King and Pennel 1964.2
- The free soft tissue graft is the most widely used, most predictable technique for increasing the zone of attached gingiva. It is a highly versatile procedure, with such unlimited potential, either solely or in conjunction with other procedures, that there is a tendency to overuse it. It is simple enough, while requiring a moderate degree of technical expertise, which is within the scope of the general dentist. Sullivan and Atkins (1968) published their classic trilogy of articles on indications, techniques, and wound healing and grafting that grafting became popular
- The classic technique includes 5 phases: pocket elimination, recipient site preparation, graft harvesting from the donor site, transferring and immobilization of the graft, and donor site protection. Some authors advocate the placement of the graft on denuded bone (Dordick et al. 1976; James & McFall 1978), reporting less shrinkage and a firmer, less mobile graft. palate, maxillary tuberosity or edentulous ridges, retromolar areas, and wide zones of gingiva; operculum over an erupting TOOTH avoid the neurovascular bundle, which includes the greater and lesser palatine nerves and blood vessels. Avoid the palatal rugae as well (Cohen 1994) Palate - This is the area where the thickest tissue can be found (Reiser et al. 1996)
- Seibert (1980) recommended the use of a full-thickness flap only in the mandibular molar areas, where the periosteum is not firmly bound down and is easily lifted off the bone. Periosteal separation – Greater graft stability., not done in mandibular premolar area because of mandibular nerve. May compromise blood supply – as blood supply in gingiva is in an apico-coronal direction.( Mormann & Colleagues, 1979)
- This procedure could be applied when augmentation of the attached gingival tissues on larger area (more than 3 teeth) in necessary. INDICATIONS: inadequate vestibule depth small alveolar bone height. Because of the limitations of the apical mucosal lap displacement for preparation of recipient site in such anatomical circumstances, a graft with small width is indicated. The dividing of the palatal gingival in two parts allows covering of wider recipient site. reduces the morbidity of the classical technique for gingival augmentation by diminishing the number of procedures in situations with generalized lack of keratinized tissues. Strips are usually 2 to 3mm. wide and should be as thin as possible (0.50 to 0.75mm thick) Donor site does not require sutures. Dry foil is placed over the strip without suturing and a surgical dressing is always used
- 3. To permit adequate transfusion of the graft, it has been recommended that all fat and glandular tissue be removed prior to suturing to prevent possible necrosis and/or inadequate take. – PLASMATIC DIFFUSION
- Oliver et al 1968 and Nobuto et al 1988 - Studied In Monkeys The initial phase (from 0 to 3 days) Thin layer of exudate is present between the graft and the recipient bed Grafted tissue survives with an avascular plasmatic circulation (red blood cell, leukocytes, plasma cells).from the recipient bed Revascularization phase (from 2 to 11 days) After 4-5 days of healing, anastomoses are established between the blood vessels of recipient bed and those in grafted tissue Capillary proliferation, fibrous union between graft and underlying CT Re-epithelialisation of the graft- by proliferation of epithelium from adjacent tissues Tissue maturation phase (from 11 to 42 days) Number of blood vessels in transplant becomes gradually reduced and after 14 days appears normal Epithelium gradually matures HOW DOES THE GRAFT APPEAR? At transplantation, graft vessels are empty & pale. First 2 days, pallor changes to ischemic gray. Pink color appears when vascularization begins. Plasmatic circulation softening & swelling of graft. Loss of epithelium graft smooth & shiny, New epithelium creates a thin, gray, veil-like surface. Healing of graft – 0.75mm – 10.5 weeks 1.75mm – 16 weeks or more DEADE SPACE - a space remaining in the tissues as a result of failure of proper closure of surgical or other wounds, permitting the accumulation of blood or serum.
- Genetic predetermination of the specific character of the oral mucosa exists that depends on stimuli originating in the connective tissue. This is the basis for the technique that uses grafts composed of only CT obtained from areas where it is covered by the keratinized epithelium. 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. 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. FGG HAVE TWO GREAT LIMITATIONS: 1. volume augmentation and aesthetic result (sometimes the color and surface doesn’t blends in with the receptor site) and soon the advantages of using subepithelial connective tissue graft (SCTG) started to be evident in the literature (B. Langer & Calagna 1980; B. Langer & L. Langer 1985).
- A classification for incision designs, relative to donor site preparation (palate) for subepithelial connective tissue grafting, was proposed by Liu et al.[11] The Liu classification of incision design helps the clinicians to decide about the incisions and also helps to achieve the most effective incision/flap design to harvest the donor tissue. Harvesting of SECTG can be done from the palate, maxillary tuberosity or edentulous ridges. The palate remains the most common donor site Class I: One incision line This classification can be used in any connective tissue graft from the palatal site. Its advantages include: 1. Only one incision line. 2. Postoperative stent is not necessary. 3. Sutures or hemostatic agents may not be necessary. 4. The incision can be applied to varying palatal forms, including high, average, and shallow . 5. Less patient discomfort (a smaller wound at 1 week postoperative). 6. More blood supply for the overlying flap. 7. Primary intention healing (in Class I type A) . Disadvantages of this type of incision are: 1. Reduced visibility of the donor site during graft preparation 2. Quite difficult to execute Class II: Two incision lines (L shape) Indications for a Class II incision are: 1. Avoidance of the greater palatine artery and nerve 2. When third incision line is not necessary Advantages are: 1. Smaller incision, but sufficient visibility 2. Moderate blood supply for the overlying flap 3. Relatively easy to execute A disadvantage of this type of incision is that two incision lines may compromise the blood supply from the donor site. Class III: Three incision lines (U shape) Indications for a Class III incision are: Concern for underlying anatomy (such as exostosis, vessels, nerves). 2. Need for larger amount of tissue Advantages are: 1. Graft size similar to the incision design 2. Greater visibility 3. Easiest to execute Disadvantages of this type of incision are: 1. More incision lines; possible compromise of the blood supply from the donor site 2. More postoperative pain; a larger wound at 1 week postoperative10 3. More sutures or stent required Subclassification (horizontal incision) Indications for a type A (one horizontal incision) design are: 1. The connective tissue graft without epithelium covering 2. Can be applied to different palatal forms, including high, average, and shallow. 3. Can be used in areas of minimal tissue depth (the thickness of donor site tissue is 3 mm or less, which is the average tissue depth in molar areas) 4. When a graft length (anteroposterior) larger than two premolars is needed8 (average tissue depth in premolar region is 5 mm; in molar region average depth is 3 mm) For a connective tissue graft that has a length greater than two premolars or greater than normal tissue depth, the use of one incision line allows harvesting of the full amount of connective tissue beneath the undermined masticatory mucosa. Indications for a type B (two horizontal incisions) design are: 1. The tissue from the palatal site has sufficient thickness. 2. The connective tissue graft with its epithelial covering. 3. The recipient site will expose the epithelial side of the graft. Average palate: The average distance from the cementoenamel junction (CEJ) to the neurovascular bundle is 12 mm. High palate: The average distance from the CEJ to the neurovascular bundle is 17 mm. Shallow palate: The average distance from the CEJ to the neurovascular bundle is 7 mm.
- Edel's[6] ‘trap-door’ technique, using vertical incisions, is popular, because of the relative ease of obtaining the connective tissue graft. Vertical incisions interrupt the vascular supply to the overlying flap predisposing the palatal flap to sloughing.[6,11,13] The use of two horizontal parallel incisions and wedge techniques, however, avoids the use of vertical incisions, but prevents primary closure of the wound.[7,8,9,11,13] The use of the single-incision technique allows primary closure of the palatal wound. The primary closure of the wound increases patient comfort, hastens the healing, reduces pain, and the chances of complications at the donor site.[10,11,13] The modified technique being a single incision technique also retains the well-documented advantages of the original technique. Raetzke[8] used two crescent-shaped horizontal incisions that converged in depth to harvest SECTG from the palate. 1. A straight, horizontal incision is begun approximately 3 mm from the free gingival margin with a no. 15 scalpel blade. The incision is begun in the molar areas and extended anteriorly. The blade is used to undermine a partial-thickness palatal flap.
- Subepithelial connective tissue graft: donor site (palatal and cross sectional views). A and A', Primary horizontal partial-thickness incision begun 5 to 7 mm from free gingival margin. B and B', Secondary horizontal incision made 2 to 3 mm from gingival margin. Incisions are directed apically to provide a connective tissue graft 1.5 to 2 mm in thickness and a length sufficient to cover the exposed root surface to be covered. C and C', Optional vertical incisions are made at the terminal ends of the graft. D and D', The primary flap is reflected. With the graft held in a tissue forceps, it is released apically with a sharp horizontal incision. E and E', The subepithelial graft is removed and the underlying submucosa exposed. F and F', Primary flap sutured with almost complete coverage obtained. Suturing can be interrupted, continuous, or suspensory. Langer and Langer developed the parallel incision method A view of the palate showing the donor site. Two horizontal '"visions These are placed 2 to 3 mm apical to the free gingival margin. are connected by vertical incisions which facilitate flap elevation and connective tissue graft removal. After the palatal flap has been elevated, the underlying connective tissue and island of epithelium are removed. This will serve “as the donor tissue. The customary thickness of the connective tissue graft will vary from 1-2 mm. This technique was modified by Harris,[7] who introduced a scalpel with two blades mounted 1.5 mm apart. PARALLEL INCISION TECHNIQUE Preoperative view. Initial graft incision seen. 1° Horizontal incision being made. 2° Horizontal incision being made. Vertical releasing incisions outlined. Note the vertical incisions are optional. Apical horizontal releasing incision is made for graft release. Connective tissue graft is freed andthe graft is trimmed to size, shape, and contour. Primary flap sutured with horizontal basting incision.
- John F. Bruno 1994 advocated another technique, in which two horizontal incisions were used to harvest SCTG. The first incision on the palate is made perpendicular to the long axis of the teeth, approximately 2 to 3 mm apical to the gingiva margin of the maxillary teeth. The mesiodistal length of the incision is determined by the length of the graft that is necessary for the recipient site. The second incision is made parallel to the long axis of the teeth, 1 to 2 mm apical ta the first incision, depending on the thickness of the graft that is required (Fig 7). The incision is carried for enough apically to provide a sufficient height of connective tissue to cover the denuded root and the adjacent periosteum of the recipient site. A small periosteal elevator is used to raise a full-thickness periosteal connective tissue graft. The donor tissue is removed from the palate as atraumatically as possible, using only the periosteal elevator. The tissue is not removed with tissue pliers, a hemostat, or any other instrument that could compress or injure the donor tissue.
- The single-incision technique for CTG harvesting provides grafts thot are suitable for all submerged and non submerged indications. The advantages of this technique are: • Only one incision is necessary parallel to the gingival margin. • There is an uncompromised blood supply for the overlying flap. • The number of sutures needed is reduced. • No postoperative stents or hemostatic agents are required. • There is primary intention healing of the donor site incision. • Variable graft sizes are obtainable. • The technique is applicable to differenf anatomic situations of the palatal vault. A possible shortcoming of this technique is the reduced visibility of the donor site during graft preparation.
- Free connective tissue graft. A, Lack of keratinized, attached gingiva buccal to central incisor. B, Vertical incisions to prepare recipient site. C, Recipient site prepared. D, Palate from which connective tissue will be removed for donor tissue. E, Removal of connective tissue. F, Donor site sutured. G, Connective tissue for graft. H, Free connective tissue placed at donor site. I, Postoperative healing at10 days. J, Final healing at 3 months. Note wide, keratinized, attached gingiva. (Courtesy Dr. M. Orisini, Italy.) Monnet-Corti and colleagues (2006) found that in the maxillary bicuspid area, regardless of vault size, it was always (100%) possible to take a 5-mm wide CT graft and 8-mm, 93% of the time.
- Can be used for pocket eradication, widening the zone of attached gingiva,or both. In the 1950s and 1960s new surgical techniques for the removal of soft and, when indicated, hard tissue periodontal pockets were described in the literature. The importance of maintaining an adequate zone of attached gingiva after surgery was now emphasized. One of the first authors to describe a technique for the preservation of the gingiva following surgery was Nabers (1954). The surgical technique developed by Nabers was originally denoted “repositioning of attached gingiva” and was later modified by Ariaudo and Tyrrell (1957). In 1962, Friedman proposed the term apically repositioned flap to describe more appropriately the surgical technique introduced by Nabers. Friedman emphasized the fact that, at the end of the surgical procedure, the entire complex of the soft tissues (gingiva and alveolar mucosa), rather than the gingiva alone, was displaced in the apical direction. Thus, rather than removing gingiva which would be in excess after osseous surgery (if performed), the whole mucogingival complex was maintained and repositioned apically. This surgical technique was used on buccal surfaces in both upper and lower jaws and on lingual surfaces in the lower jaw, To handle periodontal pockets on the palatal aspect of the maxillary teeth, Friedman described a modification of the “apically repositioned flap”, which he termed the beveled flap: while a bevel flap (see below) technique had to be used on the palatal aspect of maxillary teeth where the lack of alveolar mucosa made it impossible to reposition the flap in an apical direction. APICALLY POSITIONED FLAP Crown Lengthening Alveolar Ridge Alteration Correcting Mucogingival Defects By. Frenotomy Vestibular Deepening Increasing The Amount Of Attached Gingiva To Resist Abrasive Forces
- Friedman (1964) classified incision placement based on the amount of keratinized attached tissue present. The original APF was a full thickness mucoperiosteal flap. The apically positioned flap procedure today does not use a simple full thickness flap but rather a partial-full-thickness flap. This is a result of the inverse-beveled incision described by Friedman (1964), in which the marginal tissue and papillae are thinned or partially dissected by the initial incision. Incision Placement: Proper placement of the initial or primary inverse-beveled incision is critical when the amount of keratinized gingiva is limited.
- The modified apically repositioned flap (MARF) pro- posed in this study differs from the original in that the coronal aspect of the existing keratinized tissue is not detached from the tooth. Therefore, recession, a common finding when the original technique is used, is avoided. A horizontal beveled incision was made in the attached portion of the keratinized gingiva slightly apical to the alveolar crest (Fig. 1B). The mesial and distal extensions of the INITIAL HORIZONTAL INCISION were determined by the size of the tooth and the gingival contour. TWO VERTICAL INCISIONS were placed on the mesial and distal ends connecting the horizontal incision. These incisions extended beyond the mucogingival junction. A split-thickness flap was elevated, moved apically, and positioned at the desired level (suturing is an option) (Fig. 1C). It was then held in position by applying gentle pressure with a moist gauze for 3 to 5 minutes or until bleeding stopped. The tissue coronal to the horizontal incision was retained as a marginal collar. Dry foil was placed on the surgical area before the placement of periodontal dressing. Chlorhexidine (0.12%) was recommended twice a day for 2 weeks. The dressing was removed after 1 week. Patients were instructed not to brush the area for 2 weeks postsurgically in order to avoid damage to the gingival collar left coronally.
- Fig 1a (top left) A single horizontal beveled incision is made 0.5 MM CORONAL TO THE MUCOGINGIVAL JUNCTION. Fig 1b (top right) The flap is apically positioned to the desired level and secured with periosteal sutures. Fig 1c (right) Final result after healing, showing an increase in the apicocoronal dimension of the attached gingiva. The MARF technique uses ONE SINGLE HORIZONTAL INCISION within keratinized tissue, elevation of a SPLIT-THICKNESS FLAP, and suturing of the flap to the periosteum in an apical position. Periosteum is left exposed in the area between the initial horizontal incision and the coronal margin of the flap. The full perimeter of the exposed periosteal area is completely surrounded by keratinized tissue. Therefore, keratinized epithelial cells migrate over the periosteum during wound healing, resulting in the formation of keratinized attached tissue in the area of the previously exposed periosteum. The advantages associated with this surgical technique include its simplicity: It employs one single horizontal incision, generates minimal morbidity since it does not involve any palatal donor tissue, and provides predictable gingival color match.
- Periodontal plastic surgery
- Mucogingival therapy is a broader term than periodontal plastic surgery in that it includes nonsurgical procedures
- ANSWER : 1. Existing keratinized gingiva should always be maintained. 2. Exposing bone to increase the zone of keratinized gingiva is contraindicated (Wilderman, 1964). 3. When an adequate zone of attached keratinized gingiva exists, vestibular depth is not a factor (Bohannan, 1963a).
- 1. To create an adequate zone of attached keratinized gingiva 2. To eliminate pockets that extend beyond the mucogingival line 3. To eliminate muscle and frenulum pull 4. To deepen the vestibule 5. To cover denuded root surfaces for esthetics or hypersensitivity 6. To overcome the anatomic factors of tooth position, thin alveolar housing, and large prominent roots, which promote dehiscence and/or fenestration formation with gingival recession 7. To minimize recession during orthodontic movement 8. To overcome the trauma of prosthetic restorative dentistry requiring subgingival placement 9. To stabilize and maintain a healthy mucogingival complex 10. To correct areas of progressive gingival recession 11. To correct ridge deformities and undercuts
- Goldmen and Cohen In 1979 postulated that Dense collagenous band of connective tissue - retards or obstructs the spread of inflammation better than does the loose fibre arrangement of the alveolar mucosa.
- Prevents apical spread of inflammation. Deflects food away from gingival margin. Braces gingiva firmly against teeth. Acts as buffer between 2 moveable mucosa Bear the compressive & shear forces during mastication Prevents transmission of frenal pull.
- Free gingival autograft Free connective tissue autograft Apically positioned flap
- 1.0- 1.5mm
- Variant atechniques : Connective Tissue Technique (Edel 1974) Accordian technique (Rateitschak et al 1985) Strip technique (Han et al 1993) Combination epithelial- connective tissue technique
- Increasing zone of keratinized tissue
- 10.5 WEEKS
- 16 – 17 Weeks
- Root coverage and ridge augmentation procedures
- Strips are usually 3-5 mm(Carranza) wide and should be as thin as possible (0.50 to 0.75mm thick)
- Donor tissue - undersurface of the palatal flap - primary closure - healing is by first intention. Patient has less discomfort postoperatively at the donor site. Improved esthetics can be achieved because of a better color match of the grafted tissue to the adjacent areas.
- To eliminate periodontal pocket To increase the width of attached gingiva To lengthen the clinical crown To improve gingival and bone morphology
- Inverse/internal bevel Crevicular Interdental