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Periodontal plastic surgery

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Background of periodontal plastic surgery, indications and techniques for soft tissue grafting.

Published in: Health & Medicine, Education
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Periodontal plastic surgery

  1. 1. Soft Tissue Grafting Indications and Procedures Robert C. Cain, DDS First Mondays CE Club November 4, 2013
  2. 2. To understand some of the different types of grafts used in Periodontal Plastic Surgery (Mucogingival Surgery) To understand the indications for the different types of mucogingival surgeries To show some examples of one of the most common grafting procedures, the FGG and CTG. To understand when a condition would not benefit from Mucogingival Surgery
  3. 3. When is gingival grafting needed and when is it not? Why do I need it? What happens if I don’t do it? Does it hurt? What is the recovery time? Does it work? Does it have to be redone? Does brushing too hard cause recession? How much does it cost?
  4. 4. Attached Gingiva – The portion of the gingiva that is firm, dense, stippled and tightly bound to the underlying periosteum, tooth, and bone. Free Gingiva – That part of the gingiva that surrounds the tooth and is not directly attached to the tooth.
  5. 5. Mucogingival Junction – the area of union of the gingiva and alveolar mucosa Alveolar Mucosa – Loosely attached mucosa covering the basal part of the alveolar process and continuing into the vestibular fornix and the floor of the mouth
  6. 6. Mucogingival Defect – a departure from the normal dimension and morphology of the relationship between the gingiva and the alveolar mucosa
  7. 7. Free Gingival Graft (FGG) - A soft tissue graft that is completely detached from one site and transferred to a remote site. No connection with the donor site is maintained Subepithelial Connective Tissue Graft (CTG) - A detached connective tissue graft that is placed beneath a partial thickness flap. This variation of the free gingival graft provides the tissue graft with a nutrient supply on two surfaces
  8. 8. 1930’s – Frenectomies and vestibuloplasties 1948 – First Gingivoplasties 1956 – Grupe and Warren publish Laterally Positioned Flap 1963 – Bjorn publishes the Free Gingival Graft 1982 – P.D. Miller introduces the FGG for root coverage. Fernandez does first CT graft 1989 – AAP renames Mucogingival Surgery to Periodontal Plastic Surgery
  9. 9. Gingival Augmentation Free Gingival Graft Connective Tissue Graft Root Coverage Coronally positioned flap Semilunar flap Laterally positioned flap Double papilla flap Free Gingival Graft Connective Tissue Graft Guided Tissue Regeneration using allograft
  10. 10. How much keratinized gingivae is needed? Bowers 1963 – felt that gingival health could be maintained with a narrow zoned of KG (<1mm) but some was required for healing Lang & Loe 1968 – suggested 2mm Maynard and Wilson 1979 – 5mm of KG with 3mm attached when subgingival restorations are planned Kennedy 1985 – over a 6 year period, patients with inconsistent OH saw recession with thin tissue Bottom Line: some attached gingiva is necessary for health, but patients with good OH can maintain thin AG.
  11. 11. Is the recession progressing? Is the tooth treatment planned for orthodontic care or prosthetic treatment? Is there root sensitivity? Is there difficulty cleaning the root surface by the patient? Is there an esthetic concern?
  12. 12. Indications • To increase keratinized tissue around teeth, implants or crowns • To increase keratinized tissue under removable prostheses • To increase vestibular depth Disadvantages • • • • Difficult to achieve root coverage High esthetic demand Large, uncomfortable donor site Graft site, slow uncomfortable healing
  13. 13. Classic “Gum Graft” Will increase keratinized gingivae Results in “Tire Patch” look
  14. 14. Pre-op Pre-op Courtesy of Barry R. Wohl, DDS
  15. 15. Donor Site Recipient Site Courtesy of Barry R. Wohl, DDS
  16. 16. Before Long-term follow-up Courtesy of Barry R. Wohl, DDS
  17. 17. Class I. Recession that has not extended to MGJ. No bone loss Class II. Recession to or beyond the MGJ. No bone loss Class III. Recession to or beyond MGJ. Bone loss. Papilla recession Class IV. Recession beyond MGJ. Bone loss to the base of recession defect
  18. 18. Predisposing Factors: Minimal attached gingiva/thin tissue biotype Frenum pull / shallow vestibule Tooth malposition Precipitating Factors: Inflammation related to plaque Restorations adjacent to thin tissue Occlusal Trauma including orthodontic treatment Bone loss at an adjacent site
  19. 19. Advantages Very predictable for root coverage Smaller donor site (than FGG) Smaller recipient site (than FGG) Less soreness overall (than FGG) Uses patient’s own tissue Excellent esthetics Can cover multiple, large recessions even on teeth with a previous restorations
  20. 20. Disadvantages Two surgical sites Technique sensitive Bleeding from palate (potential)
  21. 21. Surgical technique Root preparation Thorough root planing of exposed root to remove cementum and affected dentin Etch root surface with tetracycline (pH 2.0) Exposes collagen tufts to promote fibroblast adhesion
  22. 22. Surgical Technique Incision design (tunnel technique) Create “pouch” using full/split thickness incision between gingiva and bone/root Maintain papilla for bilaminar blood supply Extend incision to adjacent teeth Undermine flap
  23. 23. Surgical Technique Donor site incision (Buser) First palatal incision perpendicular to long axis of teeth
  24. 24. Surgical Technique Donor site incision (Buser) Second palatal incision parallel to long axis of teeth
  25. 25. Donor Site Harvest Tissue Suture Palate
  26. 26. Surgical Technique Recipient site Insert graft into tunnel Suture using interrupted and sling sutures
  27. 27. Before After
  28. 28. Pre-op Occlusal Trauma Post-op
  29. 29. Miller Class IV with supra-eruption of central incisor Only minimal root coverage was possible
  30. 30. Before 3 years post-op
  31. 31. All exposed dentin is gingival recession Abfraction Tissue at or near the CEJ
  32. 32. Gingival hyperplasia adjacent to normal gingival contours
  33. 33. Does brushing too hard causes gum recession? Not really…. Toothbrushing and Gingival Recession. Litonjua, LA, et al. Int Dent J 2003 53(2) a literature review showed no direct relationship between toothbrushing and gingival recession Trauma from toothbrushing may contribute to recession in a minor way, but other more important factors should be treated first Abrasion of the hard surfaces of the teeth are likely caused by abrasives in the toothpaste
  34. 34. The common perception is that Connective Tissue Grafting is VERY PAINFUL!! This is often the patient’s perception This perception is usually the result of hearsay from friends and relatives The origins probably go back to the days of the Free Gingival Grafts
  35. 35. Reality In 20 years of performing CT grafts, very few patients ever complain about significant pain afterwards Most are pleasantly surprised at how little pain they had Very little post-op bleeding, swelling or bruising Of course, everyone’s pain threshold is different…
  36. 36. Recovery times vary from individual to individual Post-op instructions include: Soft foods for a week Avoid chewing in the donor or recipient sites if possible for the first week Bleeding from the palate is possible for the first 24 hours and sometimes longer Don’t brush the donor site for 1 week; the recipient site for 3 weeks. Chlorhexidine mouthwash in the meantime Ibuprofen 800mg 3/day for 2 – 3 days
  37. 37. Most patients report some soreness during the first week, but most do not take anything more than the Ibuprofen 800 mg Some swelling of the recipient site is normal and occasionally some bruising Sutures resorb in the palate in 2 – 3 days and in about 1 week in the recipient site Most people resume normal activities either the next day or two days after Smokers heal more slowly and results are less predictable
  38. 38. Mucogingival defects are very common across all age groups and both genders Mucogingival defects can be either congenital or acquired with both predisposing and precipitating factors Periodontal Plastic Surgery can be used to correct mucogingival defects via a variety of methods and techniques Indications for Periodontal Plastic Surgery can vary depending on rate of progression or the impact of local factors

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