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Periodontal plastic surgery

The document delineates periodontal plastic surgery, particularly mucogingival therapy, which involves surgical techniques to correct defects in gingiva and soft tissues around teeth and implants. It discusses various surgical methods to enhance the width of attached gingiva, contributing to improved aesthetics, reduced inflammation, and better dental health outcomes. Key techniques mentioned include free gingival autografts, connective tissue grafts, and several augmentation strategies to ensure proper healing and maximize the clinical results.

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Periodontal plastic surgery-1 PRESENTER DR. REBICCA RANJIT IIIrd YEAR RESIDENT
Mucogingival therapy: A general term used to describe periodontal treatment involving procedures for corrections of defects in morphology, position, &/or amount of soft tissues & underlying bone support at teeth & implants. GPT-2001
A more specific term; Introduced by Nathan Friedman in 1957. Surgical procedures designed to preserve gingiva, remove abberant frenum, or muscle attachments, and increase the depth of vestibule. Mucogingival surgery:
Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or 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,” which was originally proposed by Miller in 1993
Mucogingival surgery, Nathan Friedman, 1957 Periodontal plastic surgery, Miller, 1993 World Workshop in Clinical Periodontics,1996 Periodontal & Reconstructive surgery
Periodontal plastic surgery - broadened to include following areas Periodontal prosthetic corrections Crown lengthening Ridge augmentation Esthetic surgical corrections Esthetic surgical correction around implants Reconstruction of the papillae Surgical exposure of unerupted teeth for orthodontics Lip repositioning Gingival augmentation Coverage of the denuded root surface
The 3 objectives of periodontal plastic surgery: Problem associated with: Aberrant frenum Shallow vestibule Attached gingiva4. Esthetic surgical therapy 5. Tissue engineering
ATTACHED GINGIVA
It is the distance between the projection on the external surface of bottom of gingival sulcus or periodontal pocket (A) & mucogingival junction (B). Firm, resilient & tightly bound to underlying periosteum & is continuous with marginal gingiva.
Width of attached gingiva is greatest at the incisors and least at premolars of facial aspect (Bowers) Facial aspect Incisors (maximum) Ist Premolars (minimum) Maxilla 3.5-4.5 mm 1.9mm Mandible 3.3-3.9mm 1.8mm  Width = Total width of gingiva - Depth of sulcus AB = BC - AC
Function  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.
METHODS TO MEASURE THE WIDTH OF ATTACHED GINGIVA
 AG = Total width of gingiva  Depth of sulcus • This is done by stretching the lip or cheek to demarcate the mucogingival line while the pocket is being probed. • The amount of attached gingiva is considered to be insufficient when stretching of the lip or cheek induces movement of the free gingival margin. Visual method
Pushing the adjacent mucosa coronally with a dull instrument helps in demarcating mucogingival junction Roll test
Histochemically , by application of Schiller’s or Lugol’s potassium iodine solution which stains glycogen content.  Lugol's iodine helps to better visualize the mucogingival junction in the mouth. Alveolar mucosa has a high glycogen content that gives a positive iodine reaction. Histochemical staining method Fasske and Morgenroth
Tension test Tension applied to lip in outward, downward/upward, & lateral directions. Gingival margin is observed Any movement of the free gingiva is recorded as representing a positive response to the tension test
Adequate attached gingiva??
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 & that prevents retraction of gingival margin during movement of alveolar mucosa Lang & Loe, 1972 2mm
TISSUE BARRIER CONCEPT  Outlined by Goldman & Cohen, 1979  Postulated that:- A dense collagenous band of CT retards or obstructs the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa.  They recommended increasing the zone of attached gingiva to achieve an adequate tissue barrier (thick tissue).
WIDENING OF ATTACHED GINGIVA accomplishes following 4 objectives: a) Enhances plaque removal around gingival margin b) Improves esthetics c) Reduces inflammation around restored teeth d) Gingival margin binds better around teeth & implants with attached gingiva
SURGICAL TECHNIQUES TO INCREASE THE WIDTH OF ATTACHED GINGIVA Minimal attached gingiva with adequate vestibular depth may not require surgical correction
SURGICAL TECHNIQUES TO INCREASE THE WIDTH OF ATTACHED GINGIVA Gingival augmentation apical to recession Gingival augmentation Coronal to the recession (root coverage)
Gingival augmentation apical to recessionFree connective tissue autograft Apically reposition ed flap Free gingival autograft Bjorn,1963 Alan Edel, 1974 Introduced by Nabers, Coined by Friedman Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
Free gingival autograft  Introduced by Bjorn, 1963  Nabers introduced the term “Free gingival graft”, 1966  Described by Sullivan & Atkins, 1968
Classic technique Step 1: Prepare the recipient site The recipient site prepared by incising at the existing mucogingival junction with a #15 blade to the desired depth with periosteum left intact. To prepare a firm connective tissue bed to receive the graft.
An aluminum foil template of the recipient site can be made to be used as a pattern for the graft. Palate This is the area where the thickest tissue can be found (Reiser et al. 1996) DONOR SITE • Palate, • Maxillary tuberosity • Edentulous ridges, • Retromolar areas, and • Wide zones of gingiva; • Operculum over an erupting tooth
Step 2: Obtain the graft from the donor site: Place the template over the donor site, and make a shallow incision around it with a #15 blade Insert the blade to the desired thickness at one edge of the graft. Elevate the edge & hold it with tissue forceps Continue to separate the graft with the blade, lifting it gently as separation progresses to provide visibility. A partial-thickness graft (epithelium + a thin layer of underlying connective tissue) 5 to 6 mm
The ideal thickness of a graft = 1.0 - 1.5 mm • Peripheral layer is jeopardized due to excessive tissue that separates it from new circulation and nutrients. • Also creates a deeper wound at the donor site, with the possibility of injuring major palatal arteries (Thin enough to permit diffusion of fluid from the recipient site, which is essential in the immediate post-transplant period) Too thin graft Necrosis and exposure of the recipient site. Too thick graft
Step 3: Transfer and immobilize 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.)  Avoid excessive tension(Can distort the graft from the underlying surface.)  Avoid trauma to the graft. (Tissue forceps should be used delicately)  Minimum number of sutures used to avoid unnecessary tissue perforation PRECAUTIONS
Step 4: Protect the donor site. with a periodontal dressing for 1 week A modified Hawley retainer is useful to cover the pack on the palate and over edentulous ridges.
Gingival augmentation apical to recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique attempt to minimize the donor site morbidity
Accordion technique • Rateitschak et al • 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.
Gingival augmentation apical to recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
Strip technique • Developed by Han et al. • 2/3 strips of gingival donor tissue about 3 to 5 mm wide and long enough to cover the entire length of the recipient site. • These strips are placed side by side to form one donor tissue and sutured on the recipient site. • The area is then covered with aluminum foil and surgical dressing.
Gingival augmentation apical to recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
A deep strip graft (3 to 4 mm thick) is taken from the palate Placed between two wet tongue depressors & split it longitudinally with a sharp #15 blade. Both will be used as free grafts. Split into and Advantage:- The minimal donor site wound obtained by two donor tissues from one site. Combination technique superficial epithelial-connective tissue strip deeper pure connective strip.
Healing of free soft tissue grafts placed entirely on a connective tissue recipient bed were studied in rhesus monkeys by Oliver et al. (1968) and Nobuto et al. (1988). Healing can be divided into three phases:- Tissue maturation phase (from 11–42 days). Revascularizatio n phase (from 2–11 days) Initial phase (from 0–3 days)
• Thin layer of exudate between graft & recipient bed • Grafted tissue survive with an avascular Plasmatic circulation from the recipient bed. • Epithelium of FGG Degenerates & desquamates • Anastomoses established between blood vessels of recipient bed & those in the grafted tissue. • Circulation of blood is re-established in the pre-existing blood vessels of the graft. • Fibrous union. • Re-epithelialization of the graft. • No. of blood vessels in transplant gradually reduced. • After 14 days, vascular system appears normal. • Epithelium matures with formation of keratin layer.
Alternative Donor Tissue:- acellular dermal matrix (ADM) • Acellular. non-immunogenic scaffolds which heals by repopulation & revascularization • Derived from donated human skin; multistep proprietary process that removes epithelium with intact basement membrane to promote faster reepithelialization. RCTs have demonstrated outcomes with ADM equivalent to palatal donor tissue in treatment of gingival recession.
Free connective tissue autograft Originally described by Alan Edel, 1974 Donor connective tissue is obtained from the undersurface of the palatal flap Sutured back; therefore healing is by first intention
Free connective tissue autograft Step 1: Prepare the recipient site
Step 2: Obtain the graft from the donor site Donor connective tissue is obtained from the undersurface of the palatal flap Sutured back; therefore healing is by first intention
Step 3: Transfer and immobilize the graft.
Advantage  Connective tissue carries the genetic message for the overlying epithelium to become keratinized. Better color match of the grafted tissue to the adjacent areas. Improved esthetics can be achieved  Healing is by first intention: Less discomfort postoperatively at the donor site.
Gingival augmentation apical to recessionApically repositione d flap Can be used for pocket eradication, widening the zone of attached gingiva,or both An internal bevel incision (about 1 mm from the crest of gingiva) made Crevicular incisions followed by initial elevation of flap Interdental incision given Vertical incisions are made extending beyond the mucogingival junction
The edge of the flap may be located in 3 positions in relation to the bone: 3. 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. 2. At the level of the crest: satisfactory gingival contour, provided that the flap is adequately thinned 1. Slightly coronal to the crest of the bone: Preserve the attachment of supracrestal fibers; Result in thick gingival margins and interdental papillae with Deep sulci with the risk of recurrent pockets
SURGICAL TECHNIQUES TO INCREASE THE WIDTH OF ATTACHED GINGIVA Gingival augmentation apical to recession Gingival augmentation Coronal to the recession (root coverage)
SURGICAL NON- SURGICAL
NON-SURGICAL Periodontal management Orthodontic management Esthetic dentistry Prosthodontic management • Desensitizing toothpastes/agents • SRP • Polishing (Aimetti et al,2005) Gingival veneer:- pink autocure and heat-cured acrylics, porcelains, composite resins thermoplastic acrylics, silicone-based soft materials. New resin-based gingival-colored composites
New resin-based gingival-colored composites
Gingival veneer
SURGIC AL Pedicle soft-tissue graft procedures: a) Rotational flap procedures (laterally sliding flap, double papilla flap, oblique rotated flap); b) Advanced flap procedures (Coronally repositioned flap, Semilunar coronally repositioned flap); c)Regenerative procedures (With barrier membrane or application of enamel matrix Free soft-tissue graft procedures: a) Epithelialized graft; b) Sub-epithelial connective tissue graft
Free gingival autograft Miller Free connective tissue autograft Levine,1991 Pedicled autograft:- Laterally displaced /Coronally advanced flap Sub-epithelial connective tissue graft Langer & Langer, 1985 GTR with pedicled soft tissue graft Pini Prato et al,1992 Pouch & tunnel technique Azzi et al Pinhole surgical technique John C. Chao SURGIC AL
Step 1: Root planning Step 2: Prepare the recipient site: • Horizontal incision in IDP at right angles • Divergent vertical incisions made at the line angles of tooth to be covered, creating a partial-thickness flap to at least 5 mm apical to the receded area Steps 3 : Obtain the graft from the donor site: • 1-1.5mm partial-thickness graft harvested from palate Step 4: Transfer & immobilize the graft: • Position the graft and adapt it firmly to the recipient site; Avoid movement, excessive tension & trauma to the graft ; Cover the graft. Free gingival autograft Miller 5 mm
The difference between this technique and the free gingival autograft is that the donor tissue is Free connective tissue autograft Levine,199 connective tissue.
Pedicle Autograft
Laterally (Horizontally) Displaced Pedicle Flap: • Originally described by Grupe and Warren in 1956. • To cover isolated, denuded root surfaces • Criteria:- Donor site with adequate width of attached gingiva, minimal bone loss, & without dehiscence/fenestration. :- Adequate vestibular depth
Step 1: Prepare the recipient site. Epithelium around the denuded root surface is removed followed by thorough SRP. Step 2: Prepare the flap. Partial-thickness flap > full-thickness Rapid healing at the donor site Reduces the risk of loss of facial bone height. Only if gingiva is thin; But some loss of radicular bone (0.5mm) & recession (1.5mm)
A releasing incision (a short oblique incision into the alveolar mucosa at the distal corner of the flap, in the direction of the recipient site) to avoid tension Corn,1964
• Incomplete root coverage • Recession in the donor area • Need for an adequate donor area adjacent to the area to be treated. DISADVANTAG ES
Healing of pedicle soft tissue grafts by Wilderman & Wentz (1965) in dogs. Adaptation stage (0–4 days) Proliferation stage (4–21 days) Attachment stage (27–28 days) Maturation stage
Epithelium covering the transplanted tissue flap starts to proliferate and reaches contact with the tooth surface at the coronal edge of the flap after a few days Fibrin layer between the root surface and the flap is invaded by connective tissue proliferating from the subsurface of the flap. 6–10 days: a layer of fibroblasts in apposition to root which differentiate into cementoblasts Thin collagen fibers formed adjacent to the root surface. Epithelium proliferates apically along root surface Thin collagen fibers become inserted in a layer of new cementum. Continuous formation of collagen fibers. After 2–3 months bundles of collagen fibers insert into the cementum layer on the curetted root surface
Double-Papilla Procedure Introduced by Waienberg, 1964 Modified by Cohen & Ross, 1968 indicated in Millers Class II recession with inadequate attached gingiva but presence of sufficient width and length of interdental papilla on both sides of the area of gingival recession. Complication :- • Necrosis of the flap • Swelling & bruising at the recipient site • Deep & narrow cleft at middle surface of the root
Purpose :- To create a split-thickness flap in the area apical to the denuded root and position it coronally to cover the root. Coronally Displaced Flap 2 techniques are available for this purpose
First Technique • 2 vertical incisions extending beyond the mucogingival junction. • An internal bevel incision to eliminate diseased pocket wall. • Elevate split thickness flap followed by SRP Suture the flap at a level coronal to the pretreatment position. Periodontal dressing
Variations to First Technique (In cases with insufficient keratinized gingiva apical to the recession) Double-step procedure (Initially by Harvey, 1970 Bernimoulin et al, 1973):- Gingival augmentation procedure with free autogenous graft 2 months Coronally positioned graft
Second Technique: 2)Semilunar coronally repositioned flap Tarnow (To cover isolated denuded root surfaces or on several adjoining teeth)
Semilunar incision made following the curvature of the receded gingival margin & ending about 2-3 mm short of tip of papillae. Split-thickness dissection coronally from the incision, and connect it to an intrasulcular incision. Tissue will collapse coronally, covering the denuded root
 Indication: • Where the recession is not extensive (3 mm):-Provides 2 to 3 mm of root coverage • Facial gingival biotype is thick. • It is successful for the maxilla,  Not recommended for the mandibular dentition Semilunar coronally repositioned flap
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. Subepithelial Connective Tissue Graft (Langer & Langer in 1985)
Partial-thickness flap with: • Horizontal incision 2 mm away from the tip of papilla • 2 vertical incisions 1-2 mm away from gingival margin of the adjoining teeth Favorable esthetic result Primary healing of donor site
Bilaminar reconstruction of the gingiva using both free and pedicle layers to preserve graft viability over denuded root surfaces. Increased blood supply over the donor tissue & the gingival margin is thickened for better marginal stability. A variant of the subepithelial connective tissue graft, called a subpedicle (bilaminar) connective tissue graft, was described by Nelson in 1987. SECTG + Double papilla
Wennstorm & Zucchelli, 1996
GTR Technique for Root Coverage Pini-Prato et al, 1992 Full-thickness flap is reflected to the MGJ, continuing as a partial-thickness flap 8 mm apical to the MGJ Membrane placed over the denuded root surface and the adjacent tissue; trimmed & adapted to root surface to cover at least 2mm of marginal periosteum. suture passed through the portion of membrane; knotted on the exterior; Non-resorbable Ti-reinforced; (Tinti & Vincenzi) Resorbable
Flap is then positioned coronally & sutured. 4 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, & sutured. One week later these sutures are removed
GTR technique better when the recession is > 4.98 mm apicocoronally. Coronally displaced flap Vs GTR technique by Pini Prato
Reported:- • 3.66 mm of new connective tissue attachment • 2.48 mm of new cementum and • 1.84 mm of bone growth
Pouch & Tunnel Technique (Coronally Advanced Tunnel Technique) • Effective for the anterior maxillary area ; with adequate vestibular depth and good gingival thickness. Outlined by Azzi
Patient preparation: Plaque control instruction; SRP before the surgical procedure. 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 On the buccal aspect, sulcular incisions are made around the necks of the teeth using15c & 12D blades; extended to 1 adjacent tooth both mesially & distally .
Small, contoured blades & mini curettes are used to create the recipient pouches and tunnels. Dissect the connective tissue beyond the mucogingival line and free the buccal flap from its insertions to the bone around each tooth. Muscle fibers, any remaining collagen fibers are cut & papillae carefully undermined to allow the coronal positioning of entire gingivopapillary complex. Papillae are kept intact
Size of the pouch (including the area of the denuded root surface, is measured so that an equivalent size donor connective tissue can be procured from the tuberosity. Connective tissue harvested from the tuberosity area is contoured to fit into the recipient tunnel & pouch. mattress suture placed at one end of the graft is helpful in guiding the graft
• Tissue is gently pushed into pouch & tunnel with tissue forceps & packing instrument. Mattress suture will help maintain the graft in position
The entire gingivopapillary complex (buccal gingiva with the underlying connective tissue graft, and papillae) is coronally positioned using a horizontal mattress suture anchored at the incisal edge of the contact area. The contact areas are splinted presurgically using a composite material. • Vertical mattress suture: To hold the graft in position beneath the gingiva.
• Minimize incisions & the reflection of flap. • Provides abundant blood supply to the donor tissue, • Placement of donor connective tissue into pouches beneath papillary tunnels allows for intimate contact of donor tissue to the recipient site. • The positioning of the graft in the pouch and through the tunnel and the coronal placement of the recessed gingival margins completely covers the donor tissue. • Excellent esthetic result • Thickening of the gingival margin after healing:- stable to allow for the possibility of “creeping reattachment” of the margin ADVANTAG ES
• Requires 2 surgical sites; • Delicate harvesting of graft; • Prolonged healing time. DISADVANTAG ES
VISTA Technique Vestibular Incision Subperiosteal Tunnel Access
Pin hole surgical technique: John C. Chao  Using PST, mean % defect coverage was 94%.
CONCLUSION New techniques are constantly being developed and are slowly being incorporated into periodontal practice. Critical analysis of newly presented techniques should guide our constant evolution toward better clinical methods.
BIBLIOGRAPHY…..  Newman, Takei, Fermin A Carranza. Clinical periodontology, 12th Edition.  Jan Lindhe. Clinical Periodontology and Implant Dentistry, 5th Edition • Serge Dibart , Mamdouh Karima. Practical Periodontal Plastic Surgery. • Francisco J Otero-Cagide , M. Fermín Otero-Cagide : Unique Creeping Attachment after Autogenous Gingival Grafting: Case Report. J Can Dent Assoc 2003; 69(7):432–5 • Informational Paper: Oral Reconstructive and Corrective Considerations in Periodontal Therapy; J Periodontol 2005;76:1588-1600.
• Pini Prato GP, Tinti C, Vincenzi G, Magnani C, Cortellini , Clauser C. Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal recession. J Periodontol 1992;63:919-928. • Cortellini P. , Clauser C. , Pini Prato GP. Histologic assessment of new attachment following the treatment of a human buccal recession by means of a guided tissue regeneration procedure. J Periodontol 1993;64:387-391. • Cohen W, Ross SE. The Double Papillae Repositioned Flap in Periodontal Therapy. J Periodontol 1968;39:65-70. • Nelson SW. The subepithelial connective graft: A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102.
• Kumar PM, Reddy NR, Kumar SS, Chakrapani S. Double papilla flap technique for dual purpose. J Orofac Sci 2012;4:75-8. • Harris RJ. Double pedicle flappredictabilityand aesthetics using connective tissue. Periodont s2000, Vol.11,1996,3948 • Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-720. • Carranza FA, Jr, Carraro JJ: Mucogingival techniques in periodontal surgery. J Periodontol 41:294, 1970. • Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva. Journal of Clinical Periodontology. 1974: 1: 185- 196
• Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva. J Clin Periodontol. 1974;1:185–96. • Chao JC. A novel approach to root coverage: The pinhole surgical technique. International Journal of Periodontics and Restorative Dentistry. 2012 Oct 1;32(5):521. • Tarnow, D.P. (1986) Semilunar coronally repositioned flap. Journal of Clinical Periodontology 13, 182–185 • Bernimoulin, Luscher B. , Muhlemann HR. Coronally repositioned periodontal flap: Clinical evaluation after one year. Journal of Clinical Periodontology: 1975: 2; 1-13.
Periodontal plastic surgery

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Periodontal plastic surgery

  • 2.
  • 3.
    Mucogingival therapy: Ageneral term used to describe periodontal treatment involving procedures for corrections of defects in morphology, position, &/or amount of soft tissues & underlying bone support at teeth & implants. GPT-2001
  • 4.
    A more specificterm; Introduced by Nathan Friedman in 1957. Surgical procedures designed to preserve gingiva, remove abberant frenum, or muscle attachments, and increase the depth of vestibule. Mucogingival surgery:
  • 5.
    Periodontal plastic surgeryis defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or 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,” which was originally proposed by Miller in 1993
  • 6.
    Mucogingival surgery, Nathan Friedman,1957 Periodontal plastic surgery, Miller, 1993 World Workshop in Clinical Periodontics,1996 Periodontal & Reconstructive surgery
  • 7.
    Periodontal plastic surgery- broadened to include following areas Periodontal prosthetic corrections Crown lengthening Ridge augmentation Esthetic surgical corrections Esthetic surgical correction around implants Reconstruction of the papillae Surgical exposure of unerupted teeth for orthodontics Lip repositioning Gingival augmentation Coverage of the denuded root surface
  • 8.
    The 3 objectivesof periodontal plastic surgery: Problem associated with: Aberrant frenum Shallow vestibule Attached gingiva4. Esthetic surgical therapy 5. Tissue engineering
  • 9.
  • 10.
    It is thedistance between the projection on the external surface of bottom of gingival sulcus or periodontal pocket (A) & mucogingival junction (B). Firm, resilient & tightly bound to underlying periosteum & is continuous with marginal gingiva.
  • 11.
    Width of attachedgingiva is greatest at the incisors and least at premolars of facial aspect (Bowers) Facial aspect Incisors (maximum) Ist Premolars (minimum) Maxilla 3.5-4.5 mm 1.9mm Mandible 3.3-3.9mm 1.8mm  Width = Total width of gingiva - Depth of sulcus AB = BC - AC
  • 12.
    Function  Prevents apicalspread 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.
  • 13.
    METHODS TO MEASURE THEWIDTH OF ATTACHED GINGIVA
  • 14.
     AG =Total width of gingiva  Depth of sulcus • This is done by stretching the lip or cheek to demarcate the mucogingival line while the pocket is being probed. • The amount of attached gingiva is considered to be insufficient when stretching of the lip or cheek induces movement of the free gingival margin. Visual method
  • 15.
    Pushing the adjacentmucosa coronally with a dull instrument helps in demarcating mucogingival junction Roll test
  • 16.
    Histochemically , byapplication of Schiller’s or Lugol’s potassium iodine solution which stains glycogen content.  Lugol's iodine helps to better visualize the mucogingival junction in the mouth. Alveolar mucosa has a high glycogen content that gives a positive iodine reaction. Histochemical staining method Fasske and Morgenroth
  • 17.
    Tension test Tension appliedto lip in outward, downward/upward, & lateral directions. Gingival margin is observed Any movement of the free gingiva is recorded as representing a positive response to the tension test
  • 18.
  • 19.
    VARIOUS AUTHORS ADEQUATEATTACHED GINGIVA Corn, 1962 > 3mm (Keratinized gingiva) Bowers, 1963 <1 mm Friedman, 1962; De Trey & Bernimoulin, 1980 Gingiva that is compatible to gingival health & that prevents retraction of gingival margin during movement of alveolar mucosa Lang & Loe, 1972 2mm
  • 20.
    TISSUE BARRIER CONCEPT Outlined by Goldman & Cohen, 1979  Postulated that:- A dense collagenous band of CT retards or obstructs the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa.  They recommended increasing the zone of attached gingiva to achieve an adequate tissue barrier (thick tissue).
  • 21.
    WIDENING OF ATTACHEDGINGIVA accomplishes following 4 objectives: a) Enhances plaque removal around gingival margin b) Improves esthetics c) Reduces inflammation around restored teeth d) Gingival margin binds better around teeth & implants with attached gingiva
  • 22.
    SURGICAL TECHNIQUES TO INCREASETHE WIDTH OF ATTACHED GINGIVA Minimal attached gingiva with adequate vestibular depth may not require surgical correction
  • 23.
    SURGICAL TECHNIQUES TO INCREASETHE WIDTH OF ATTACHED GINGIVA Gingival augmentation apical to recession Gingival augmentation Coronal to the recession (root coverage)
  • 24.
    Gingival augmentation apicalto recessionFree connective tissue autograft Apically reposition ed flap Free gingival autograft Bjorn,1963 Alan Edel, 1974 Introduced by Nabers, Coined by Friedman Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
  • 25.
    Free gingival autograft  Introducedby Bjorn, 1963  Nabers introduced the term “Free gingival graft”, 1966  Described by Sullivan & Atkins, 1968
  • 26.
    Classic technique Step 1:Prepare the recipient site The recipient site prepared by incising at the existing mucogingival junction with a #15 blade to the desired depth with periosteum left intact. To prepare a firm connective tissue bed to receive the graft.
  • 27.
    An aluminum foiltemplate of the recipient site can be made to be used as a pattern for the graft. Palate This is the area where the thickest tissue can be found (Reiser et al. 1996) DONOR SITE • Palate, • Maxillary tuberosity • Edentulous ridges, • Retromolar areas, and • Wide zones of gingiva; • Operculum over an erupting tooth
  • 28.
    Step 2: Obtainthe graft from the donor site: Place the template over the donor site, and make a shallow incision around it with a #15 blade Insert the blade to the desired thickness at one edge of the graft. Elevate the edge & hold it with tissue forceps Continue to separate the graft with the blade, lifting it gently as separation progresses to provide visibility. A partial-thickness graft (epithelium + a thin layer of underlying connective tissue) 5 to 6 mm
  • 29.
    The ideal thicknessof a graft = 1.0 - 1.5 mm • Peripheral layer is jeopardized due to excessive tissue that separates it from new circulation and nutrients. • Also creates a deeper wound at the donor site, with the possibility of injuring major palatal arteries (Thin enough to permit diffusion of fluid from the recipient site, which is essential in the immediate post-transplant period) Too thin graft Necrosis and exposure of the recipient site. Too thick graft
  • 30.
    Step 3: Transferand immobilize 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.
  • 31.
     The graftmust be immobilized (Any movement interferes with healing.)  Avoid excessive tension(Can distort the graft from the underlying surface.)  Avoid trauma to the graft. (Tissue forceps should be used delicately)  Minimum number of sutures used to avoid unnecessary tissue perforation PRECAUTIONS
  • 32.
    Step 4: Protectthe donor site. with a periodontal dressing for 1 week A modified Hawley retainer is useful to cover the pack on the palate and over edentulous ridges.
  • 33.
    Gingival augmentation apicalto recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique attempt to minimize the donor site morbidity
  • 34.
    Accordion technique • Rateitschaket al • 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.
  • 35.
    Gingival augmentation apicalto recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
  • 36.
    Strip technique • Developedby Han et al. • 2/3 strips of gingival donor tissue about 3 to 5 mm wide and long enough to cover the entire length of the recipient site. • These strips are placed side by side to form one donor tissue and sutured on the recipient site. • The area is then covered with aluminum foil and surgical dressing.
  • 37.
    Gingival augmentation apicalto recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
  • 38.
    A deep stripgraft (3 to 4 mm thick) is taken from the palate Placed between two wet tongue depressors & split it longitudinally with a sharp #15 blade. Both will be used as free grafts. Split into and Advantage:- The minimal donor site wound obtained by two donor tissues from one site. Combination technique superficial epithelial-connective tissue strip deeper pure connective strip.
  • 39.
    Healing of freesoft tissue grafts placed entirely on a connective tissue recipient bed were studied in rhesus monkeys by Oliver et al. (1968) and Nobuto et al. (1988). Healing can be divided into three phases:- Tissue maturation phase (from 11–42 days). Revascularizatio n phase (from 2–11 days) Initial phase (from 0–3 days)
  • 40.
    • Thin layerof exudate between graft & recipient bed • Grafted tissue survive with an avascular Plasmatic circulation from the recipient bed. • Epithelium of FGG Degenerates & desquamates • Anastomoses established between blood vessels of recipient bed & those in the grafted tissue. • Circulation of blood is re-established in the pre-existing blood vessels of the graft. • Fibrous union. • Re-epithelialization of the graft. • No. of blood vessels in transplant gradually reduced. • After 14 days, vascular system appears normal. • Epithelium matures with formation of keratin layer.
  • 41.
    Alternative Donor Tissue:-acellular dermal matrix (ADM) • Acellular. non-immunogenic scaffolds which heals by repopulation & revascularization • Derived from donated human skin; multistep proprietary process that removes epithelium with intact basement membrane to promote faster reepithelialization. RCTs have demonstrated outcomes with ADM equivalent to palatal donor tissue in treatment of gingival recession.
  • 42.
    Free connective tissue autograft Originallydescribed by Alan Edel, 1974 Donor connective tissue is obtained from the undersurface of the palatal flap Sutured back; therefore healing is by first intention
  • 43.
    Free connective tissue autograft Step1: Prepare the recipient site
  • 44.
    Step 2: Obtainthe graft from the donor site Donor connective tissue is obtained from the undersurface of the palatal flap Sutured back; therefore healing is by first intention
  • 45.
    Step 3: Transferand immobilize the graft.
  • 46.
    Advantage  Connective tissuecarries the genetic message for the overlying epithelium to become keratinized. Better color match of the grafted tissue to the adjacent areas. Improved esthetics can be achieved  Healing is by first intention: Less discomfort postoperatively at the donor site.
  • 47.
    Gingival augmentation apicalto recessionApically repositione d flap Can be used for pocket eradication, widening the zone of attached gingiva,or both An internal bevel incision (about 1 mm from the crest of gingiva) made Crevicular incisions followed by initial elevation of flap Interdental incision given Vertical incisions are made extending beyond the mucogingival junction
  • 49.
    The edge ofthe flap may be located in 3 positions in relation to the bone: 3. 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. 2. At the level of the crest: satisfactory gingival contour, provided that the flap is adequately thinned 1. Slightly coronal to the crest of the bone: Preserve the attachment of supracrestal fibers; Result in thick gingival margins and interdental papillae with Deep sulci with the risk of recurrent pockets
  • 50.
    SURGICAL TECHNIQUES TO INCREASETHE WIDTH OF ATTACHED GINGIVA Gingival augmentation apical to recession Gingival augmentation Coronal to the recession (root coverage)
  • 51.
  • 52.
    NON-SURGICAL Periodontal management Orthodontic management Esthetic dentistry Prosthodontic management • Desensitizing toothpastes/agents • SRP •Polishing (Aimetti et al,2005) Gingival veneer:- pink autocure and heat-cured acrylics, porcelains, composite resins thermoplastic acrylics, silicone-based soft materials. New resin-based gingival-colored composites
  • 53.
  • 54.
  • 55.
    SURGIC AL Pedicle soft-tissue graftprocedures: a) Rotational flap procedures (laterally sliding flap, double papilla flap, oblique rotated flap); b) Advanced flap procedures (Coronally repositioned flap, Semilunar coronally repositioned flap); c)Regenerative procedures (With barrier membrane or application of enamel matrix Free soft-tissue graft procedures: a) Epithelialized graft; b) Sub-epithelial connective tissue graft
  • 56.
    Free gingival autograftMiller Free connective tissue autograft Levine,1991 Pedicled autograft:- Laterally displaced /Coronally advanced flap Sub-epithelial connective tissue graft Langer & Langer, 1985 GTR with pedicled soft tissue graft Pini Prato et al,1992 Pouch & tunnel technique Azzi et al Pinhole surgical technique John C. Chao SURGIC AL
  • 57.
    Step 1: Rootplanning Step 2: Prepare the recipient site: • Horizontal incision in IDP at right angles • Divergent vertical incisions made at the line angles of tooth to be covered, creating a partial-thickness flap to at least 5 mm apical to the receded area Steps 3 : Obtain the graft from the donor site: • 1-1.5mm partial-thickness graft harvested from palate Step 4: Transfer & immobilize the graft: • Position the graft and adapt it firmly to the recipient site; Avoid movement, excessive tension & trauma to the graft ; Cover the graft. Free gingival autograft Miller 5 mm
  • 58.
    The difference betweenthis technique and the free gingival autograft is that the donor tissue is Free connective tissue autograft Levine,199 connective tissue.
  • 59.
  • 60.
    Laterally (Horizontally) DisplacedPedicle Flap: • Originally described by Grupe and Warren in 1956. • To cover isolated, denuded root surfaces • Criteria:- Donor site with adequate width of attached gingiva, minimal bone loss, & without dehiscence/fenestration. :- Adequate vestibular depth
  • 61.
    Step 1: Preparethe recipient site. Epithelium around the denuded root surface is removed followed by thorough SRP. Step 2: Prepare the flap. Partial-thickness flap > full-thickness Rapid healing at the donor site Reduces the risk of loss of facial bone height. Only if gingiva is thin; But some loss of radicular bone (0.5mm) & recession (1.5mm)
  • 62.
    A releasing incision(a short oblique incision into the alveolar mucosa at the distal corner of the flap, in the direction of the recipient site) to avoid tension Corn,1964
  • 63.
    • Incomplete rootcoverage • Recession in the donor area • Need for an adequate donor area adjacent to the area to be treated. DISADVANTAG ES
  • 64.
    Healing of pediclesoft tissue grafts by Wilderman & Wentz (1965) in dogs. Adaptation stage (0–4 days) Proliferation stage (4–21 days) Attachment stage (27–28 days) Maturation stage
  • 65.
    Epithelium covering thetransplanted tissue flap starts to proliferate and reaches contact with the tooth surface at the coronal edge of the flap after a few days Fibrin layer between the root surface and the flap is invaded by connective tissue proliferating from the subsurface of the flap. 6–10 days: a layer of fibroblasts in apposition to root which differentiate into cementoblasts Thin collagen fibers formed adjacent to the root surface. Epithelium proliferates apically along root surface Thin collagen fibers become inserted in a layer of new cementum. Continuous formation of collagen fibers. After 2–3 months bundles of collagen fibers insert into the cementum layer on the curetted root surface
  • 66.
    Double-Papilla Procedure Introduced byWaienberg, 1964 Modified by Cohen & Ross, 1968 indicated in Millers Class II recession with inadequate attached gingiva but presence of sufficient width and length of interdental papilla on both sides of the area of gingival recession. Complication :- • Necrosis of the flap • Swelling & bruising at the recipient site • Deep & narrow cleft at middle surface of the root
  • 67.
    Purpose :- Tocreate a split-thickness flap in the area apical to the denuded root and position it coronally to cover the root. Coronally Displaced Flap 2 techniques are available for this purpose
  • 68.
    First Technique • 2vertical incisions extending beyond the mucogingival junction. • An internal bevel incision to eliminate diseased pocket wall. • Elevate split thickness flap followed by SRP Suture the flap at a level coronal to the pretreatment position. Periodontal dressing
  • 69.
    Variations to FirstTechnique (In cases with insufficient keratinized gingiva apical to the recession) Double-step procedure (Initially by Harvey, 1970 Bernimoulin et al, 1973):- Gingival augmentation procedure with free autogenous graft 2 months Coronally positioned graft
  • 71.
    Second Technique: 2)Semilunar coronallyrepositioned flap Tarnow (To cover isolated denuded root surfaces or on several adjoining teeth)
  • 72.
    Semilunar incision madefollowing the curvature of the receded gingival margin & ending about 2-3 mm short of tip of papillae. Split-thickness dissection coronally from the incision, and connect it to an intrasulcular incision. Tissue will collapse coronally, covering the denuded root
  • 73.
     Indication: • Wherethe recession is not extensive (3 mm):-Provides 2 to 3 mm of root coverage • Facial gingival biotype is thick. • It is successful for the maxilla,  Not recommended for the mandibular dentition Semilunar coronally repositioned flap
  • 74.
    Larger and multipledefects 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. Subepithelial Connective Tissue Graft (Langer & Langer in 1985)
  • 75.
    Partial-thickness flap with: •Horizontal incision 2 mm away from the tip of papilla • 2 vertical incisions 1-2 mm away from gingival margin of the adjoining teeth Favorable esthetic result Primary healing of donor site
  • 76.
    Bilaminar reconstruction ofthe gingiva using both free and pedicle layers to preserve graft viability over denuded root surfaces. Increased blood supply over the donor tissue & the gingival margin is thickened for better marginal stability. A variant of the subepithelial connective tissue graft, called a subpedicle (bilaminar) connective tissue graft, was described by Nelson in 1987. SECTG + Double papilla
  • 77.
  • 78.
    GTR Technique forRoot Coverage Pini-Prato et al, 1992 Full-thickness flap is reflected to the MGJ, continuing as a partial-thickness flap 8 mm apical to the MGJ Membrane placed over the denuded root surface and the adjacent tissue; trimmed & adapted to root surface to cover at least 2mm of marginal periosteum. suture passed through the portion of membrane; knotted on the exterior; Non-resorbable Ti-reinforced; (Tinti & Vincenzi) Resorbable
  • 79.
    Flap is thenpositioned coronally & sutured. 4 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, & sutured. One week later these sutures are removed
  • 80.
    GTR technique betterwhen the recession is > 4.98 mm apicocoronally. Coronally displaced flap Vs GTR technique by Pini Prato
  • 81.
    Reported:- • 3.66 mmof new connective tissue attachment • 2.48 mm of new cementum and • 1.84 mm of bone growth
  • 82.
    Pouch & TunnelTechnique (Coronally Advanced Tunnel Technique) • Effective for the anterior maxillary area ; with adequate vestibular depth and good gingival thickness. Outlined by Azzi
  • 83.
    Patient preparation: Plaquecontrol instruction; SRP before the surgical procedure. 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 On the buccal aspect, sulcular incisions are made around the necks of the teeth using15c & 12D blades; extended to 1 adjacent tooth both mesially & distally .
  • 84.
    Small, contoured blades& mini curettes are used to create the recipient pouches and tunnels. Dissect the connective tissue beyond the mucogingival line and free the buccal flap from its insertions to the bone around each tooth. Muscle fibers, any remaining collagen fibers are cut & papillae carefully undermined to allow the coronal positioning of entire gingivopapillary complex. Papillae are kept intact
  • 85.
    Size of thepouch (including the area of the denuded root surface, is measured so that an equivalent size donor connective tissue can be procured from the tuberosity. Connective tissue harvested from the tuberosity area is contoured to fit into the recipient tunnel & pouch. mattress suture placed at one end of the graft is helpful in guiding the graft
  • 86.
    • Tissue isgently pushed into pouch & tunnel with tissue forceps & packing instrument. Mattress suture will help maintain the graft in position
  • 87.
    The entire gingivopapillarycomplex (buccal gingiva with the underlying connective tissue graft, and papillae) is coronally positioned using a horizontal mattress suture anchored at the incisal edge of the contact area. The contact areas are splinted presurgically using a composite material. • Vertical mattress suture: To hold the graft in position beneath the gingiva.
  • 88.
    • Minimize incisions& the reflection of flap. • Provides abundant blood supply to the donor tissue, • Placement of donor connective tissue into pouches beneath papillary tunnels allows for intimate contact of donor tissue to the recipient site. • The positioning of the graft in the pouch and through the tunnel and the coronal placement of the recessed gingival margins completely covers the donor tissue. • Excellent esthetic result • Thickening of the gingival margin after healing:- stable to allow for the possibility of “creeping reattachment” of the margin ADVANTAG ES
  • 89.
    • Requires 2surgical sites; • Delicate harvesting of graft; • Prolonged healing time. DISADVANTAG ES
  • 90.
    VISTA Technique Vestibular IncisionSubperiosteal Tunnel Access
  • 91.
    Pin hole surgicaltechnique: John C. Chao  Using PST, mean % defect coverage was 94%.
  • 92.
    CONCLUSION New techniques areconstantly being developed and are slowly being incorporated into periodontal practice. Critical analysis of newly presented techniques should guide our constant evolution toward better clinical methods.
  • 93.
    BIBLIOGRAPHY…..  Newman, Takei,Fermin A Carranza. Clinical periodontology, 12th Edition.  Jan Lindhe. Clinical Periodontology and Implant Dentistry, 5th Edition • Serge Dibart , Mamdouh Karima. Practical Periodontal Plastic Surgery. • Francisco J Otero-Cagide , M. Fermín Otero-Cagide : Unique Creeping Attachment after Autogenous Gingival Grafting: Case Report. J Can Dent Assoc 2003; 69(7):432–5 • Informational Paper: Oral Reconstructive and Corrective Considerations in Periodontal Therapy; J Periodontol 2005;76:1588-1600.
  • 94.
    • Pini PratoGP, Tinti C, Vincenzi G, Magnani C, Cortellini , Clauser C. Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal recession. J Periodontol 1992;63:919-928. • Cortellini P. , Clauser C. , Pini Prato GP. Histologic assessment of new attachment following the treatment of a human buccal recession by means of a guided tissue regeneration procedure. J Periodontol 1993;64:387-391. • Cohen W, Ross SE. The Double Papillae Repositioned Flap in Periodontal Therapy. J Periodontol 1968;39:65-70. • Nelson SW. The subepithelial connective graft: A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102.
  • 95.
    • Kumar PM,Reddy NR, Kumar SS, Chakrapani S. Double papilla flap technique for dual purpose. J Orofac Sci 2012;4:75-8. • Harris RJ. Double pedicle flappredictabilityand aesthetics using connective tissue. Periodont s2000, Vol.11,1996,3948 • Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-720. • Carranza FA, Jr, Carraro JJ: Mucogingival techniques in periodontal surgery. J Periodontol 41:294, 1970. • Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva. Journal of Clinical Periodontology. 1974: 1: 185- 196
  • 96.
    • Edel A.Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva. J Clin Periodontol. 1974;1:185–96. • Chao JC. A novel approach to root coverage: The pinhole surgical technique. International Journal of Periodontics and Restorative Dentistry. 2012 Oct 1;32(5):521. • Tarnow, D.P. (1986) Semilunar coronally repositioned flap. Journal of Clinical Periodontology 13, 182–185 • Bernimoulin, Luscher B. , Muhlemann HR. Coronally repositioned periodontal flap: Clinical evaluation after one year. Journal of Clinical Periodontology: 1975: 2; 1-13.

Editor's Notes

  • #18 The alveolar mucosa differs from keratinized gingiva histochemically in its glycogen content, acid phosphatase and nonspecific esterase content and an increased amount of elastic fiber content within the corium resulting in an iodo-positive reaction.The attached gingiva, which is keratinized, has no glycogen in the most superficial layer and gives an iodo-negative reaction. Thus, Lugol’s iodine solution stains only the alveolar mucosa and clearly demarcates the mucogingival junction.
  • #28 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
  • #29 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)
  • #31 Proper thickness is important for survival of the graft. A thick graft can be thinned by holding it between two wet wooden tongue depressors and slicing it longitudinally with a sharp #15 blade
  • #32 Remove the excess clot. A thick clot interferes with vascularization of the graft revascularization occurs from both the periosteal or osseous base and the overlying flap. This dual blood supply is responsible for the increased predictability of CTG procedures
  • #43 capillary proliferation, which gradually results in a dense network of blood vessels in the graft Fibrous union is established between the graft and the underlying connective tissue bed. Re-epithelialization of the graft occurs mainly by proliferation of epithelium from the adjacent tissues. Ensure establishment & maintenance of plasmatic circulation by fluorescein angiography
  • #44 avoiding palatal donor surgery, ADM offers the advantage of availability of unlimited donor tissue for treatment of multiple teeth in a single surgical appointment. Two surgical techniques are suggested for use of ADM in treating gingival recession. Each is a coronally positioned pouch method. The frst is the alternate papilla tunnel (APT) method and the second is the papilla retention pouch (PRP) method
  • #45 Palate; saddle area of edentulous ridges
  • #48 Final healing at 3 months. Note wide, keratinized, attached gingiva
  • #50 A dry foil is placed over the flap before it is covered with the dressing to prevent the introduction of pack under the flap
  • #51 A, Internal bevel incision (I) separates inner wall of periodontal pocket.. B, Partial-thickness flap (F) separated, leaving periosteum and a layer of connective tissue on the bone. The inner wall of the periodontal pocket (I) is removed, and the tooth is scaled and planed. C, Partial-thickness flap (F) displaced apically, with edge of the flap at crest of the bone. D, Partial thickness flap (F) displaced apically, with edge of the flap several millimeters below crest of the bone.
  • #52 Placing the flap short of the crest increases the risk of a slight reduction in bone height, but the advantage of a well-formed gingival margin compensates for this
  • #55 coverage of exposed root surfaces cannot be achieved but hinders the advance of a periodontal recession and limit the potential damage Burstone 1977 first described Intrusion mechanics for orthodontic tooth movement.
  • #60 citric acid for 5 minutes to create a margin against which the graft may have a butt joint with the incision. shallow incision with a #15 blade Elevate the edge and hold it with tissue forceps. Continue to separate the graft with the blade, lifting it gently as separation progresses to provide visibility Epithelialized masticatory mucosa from the palate; adequate donor tissue; a functional result is produced dead space impairs vascularization and jeopardizes the graft
  • #63 For over 25 years, the only surgical procedure available that could aesthetic, since the color match is ideal. predictably produce root coverage.
  • #64 The periodontium of the donor site should have a satisfactory width of attached gingiva and minimal loss of bone, without dehiscence or fenestration.
  • #65 With a #15 blade, a vertical incision is made from the gingival margin to outline a flap adjacent to the recipient site. The flap should be sufficiently wider than the recipient site 1 year healing
  • #66 For over 25 years, the only surgical procedure available that could aesthetic, since the color match is ideal. predictably produce root coverage.
  • #68 fl ap is separated from the exposed root surface by a thin fibrin layer.
  • #69 Root conditioning—Sulcular & vertical incision in LA of adjacent teeth to raise partial thickness flap– Advance flap coronally and suture the 2 halves of IDP each from adjacent teeth poor predictability and the technical skill levels
  • #71 from the gingival margin to the bottom of the pocket
  • #72 . This creates several millimeters of attached keratinized gingiva apical to the denuded root
  • #73 A,Preoperative view. Note the recession and the lack of attached gingiva. B,After placement of a free gingival graft. C,Three months after placement of the graft. D,Flap, including the graft, positioned coronally and sutured. E,Six months later. Note the root coverage and the presence of attached gingiva. Compare with A disadvantage : free graft may heal as scar tissue and then be difficult to elevate by blunt dissection; requires sharp dissection that can lead to excessive thinning or flap perforation
  • #74 particularly in covering roots left exposed by the gingival margin receding from a recently placed crown margin.
  • #75 This location is very important because the flap derives its blood supply from the papillary areas. It is then held in its new position for a few minutes with a moist gauze. No sutures or periodontal dressing.
  • #78 CT graft from the palate by means of a horizontal incision 5 to 6 mm from the gingival margin of molars & premolars; sutured in a primary closure Trapdoor tech by edel; parallel incision method by langer & langer Place the connective tissue on the denuded root(s). Suture it with resorbable sutures to the periosteum Cover the graft with the outer portion of the partial thickness flap and suture it interdentally. predictably increased the root coverage of Miller's Class I and II recession[3] to around 90%.
  • #79 The double papilla flap has been used to cover denuded root surfaces when a sufficient amount of attached gingiva is not present on adjacent teeth. The most common failure of this procedure is the appearance of a deep and narrow cleft at the middle surface of the root. The subpedicle connective tissue graft functions to prevent clefting by providing a connective tissue base
  • #81 space allows for the growth of tissue beneath the membrane. inability to create space; even though not needing a second surgery
  • #86 Coronal positioning of the entire gingivopapillary unit by the use of a horizontal mattress suture anchored over the splinted incisal portion of the contact
  • #88 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. Saline moistened gauze is placed over the recipient site.
  • #90 Other holding sutures may be placed through the overlying gingival tissue and donor tissue to the underlying periosteum to secure and stabilize the donor tissue and the overlying gingiva in a coronal position
  • #91 described by Goldman and Cohen5 as the postoperative migration of the gingival marginal tissue in a coronal direction over portions of a previously denuded root; detected 1 to 12 months after graft surgery with an average coverage of about 1 mm. Factors which favor creeping attachment are narrowness of the recession, the presence of bone positioned more coronally interproximally than on the facial surface, absence of gross tooth malpositioning, and adequate plaque control.
  • #94 Trans-mucosal papillae elevators {TMPEs}) inserted through the entry incision to elevate full thickness flap. Flap then extended coronally & horizontally to allow for elevation of 2 adjacent papillae on each side of the denuded roots. inclusion of at least 4 papillae threaded 1 by 1 through the entry incision using PST graft pliers