case report of Periosteal pedicle graft-novel technique
1.
2. Periosteal Pedicle Graft:– A Novel Technique
For Root Coverage
Department Of Periodontics
Narayana Dental College & Hospital
3. Introduction
• One of t he long t erm desires of
Periodont ist s ---able t o cover denuded
root surf aces.
• Pat ient awareness and expect at ions have
increased recent ly t o t he point t hat less
t han opt imal aest het ics are no longer an
4. Gingival recession
Marginal Tissue Recession – Maynard and
Wilson(1968)
Periodont al Recession – Sant arelli GA et al (2001)
• Gingival recession is def ined as t he locat ion of
marginal t issue apical t o cement o-enamel
j unct ion wit h exposure of root sur f ace.
(Wennst r om J , Pini Prat o GP).
4
5. Etiology
– Fault y t oot h br ushing t echnique
– Toot h malposit ion
– Gingival inf lammat ion
– Abnor mal f r enal at t achment
– Tr auma f r om occlusion
– Masochist ic habit s
– Frict ion f rom sof t t issues
– I at rogenic dent ist ry
6. Classifications of gingival
recession
• 1968 – Sullivan and At kins
• 1978 – Mlineck
• 1980 – Liu and Salt
• 1983 – Bengue et al.,
• 1985 – Prest on D Miller J r
• 2010 – Mahaj an’s Modif icat ion
8. Patient Evaluation
Assessing t he amount of root coverage
t hat can be achieved requires
Width of the defect,
Evaluation of the height of the
interproximal tissues,
Allen f ound t hat width is inversely
9. Pedicle Flaps
•Advanced Flaps
•Rot at ional Flaps
Free soft tissue grafts
•Non submerged graf t s - Free
gingival graf t s
•Aut ogenous submerged sof t
t issue graf t s
•Allogenic sof t t issue graf t -
Alloderm
Guided Tissue
Regeneration
Resorbable bar rier
membr anes
•Aut ogenous - Fascia (callan,
1990)
•Xenograf t s - Collagen
membranes
Non Resorbable Bar rier
Membr anes
•PTFE
GTR membrane + Bone
Gr af t s
Additive Treatments
• Root modif icat ion
agent s : Cit ric acid,
Classification of Root Coverage
Procedures
10. HISTORY
• LPF-Grupe &Warren 1956
• FGG- Bj orn; Sullivan & At kins 1963
• Double- Papillae Laterally Positioned
Flaps—Wainberg 1964
• CAF- Bernimoulin et al. 1975
• SECT- Langer &Langer 1985
• Acellular Dermal matrix- Silverst ein &
Callan 1997.
• Periosteal pedicle flap- Aj ay Mahaj an
11. • Autogenous submerged soft tissue
grafts
– Sub Epit helial Connect ive Tissue Gr af t
11
Disadvantage: morbidit y
Search f or bet t er alt ernat ive……………..
12. AIM : To demonst rat e a novel t echnique t hat ut ilizes
t he per iost eum as an aut ogr af t f or t he t reat ment
of gingival recession def ect .
The adult human periosteum is a highly vascular
connect ive t issue wit h immense r egenerat ive
pot ent ial. These qualit ies make it a suit able
aut ogenous gr af t .
13. Inclusion criteria-
• Non-compr omised syst emic healt h,
• No cont r aindicat ion f or per iodont al sur ger y,
• Miller Class I or I I r ecession def ect s ≥2 mm in
upper and/ or lower t eet h
• Fr ee of per iapical pat hology.
Exclusion criteria –
Smoker s, chewer s of t obacco, endodont ically
t r eat ed sit es, r oot surf ace r est orat ions,
14. CASE
Age/Sex : 32 Years/Male
Chief Compliant : Compromised Esthetics
Medical and dental history- Non -contributory
Gingival Recession :Millers Class–I
{Recession Depth –4mm, Recession Width – 3.5mm}
Probing Depth – 0.5mm
Width Of Keratinized Gingiva – 1mm
15. Technique
A.Horizontal & vertical incisions placed
B.2 mm of Alveolar bone exposed
C.Periosteum is reflected from the apical end, leaving the coronal end intact
D.Periosteum is reversed over the recession defect
E.Coronal advancement of partial thickness flap done
16. • Horizontal & vertical incisions placed
Technique• 2 mm of Alveolar bone exposed
Periosteum
Partial thickness flap
Exposed alveolar bone
17. Technique
• Periosteum is reflected from the apical end,
leaving the coronal end intact
• Periosteum is reversed over the recession defect
21. • Search f or single universal t echnique
t hat can be used wit h high
predict abilit y, ef f ect iveness, and
ef f iciency wit hout compromising pat ient
cent ered crit eria like pain,
post operat ive est het ic out comes and
cost s of t reat ment !!!!!!!!!
22. • The periost eum, which is a highly vascular
t issue, is comprised of 2 layers, an inner
cellular or cambium layer and an out er
f ibrous layer
• Wound healing af t er mucogingival surgery
relies on clot t ing, revascularizat ion, and
maint enance of blood supply. Also,Hwang DL, Wang : J Periodontol 2006;77:1625-1634.
23. I n addit ion, having an adequat e vascularit y
prevent s t he necrosis of PPG even if it is
lef t uncovered by t he overlying f lap,
especially in t he case of a large area of
gingival recession.
A. Mahajan, J Periodontol 2010;81:1426-1431.
Vascularized periost eal f laps ---excellent
ost eogenic capacit y
24. • The presence of pluripot ent ial
mesenchymal cells in t he under surf ace
of t he periost eum in combinat ion wit h
growt h f act ors like vascular endot helial
growt h f act or regularly produced or
released af t er inj ury, provide t his
unique t issue wit h an import ant role in
t he healing of bone.
• The Periost eum cont ribut es t o t he
eliminat ion of long j unct ional epit helium
f ormat ion and f acilit at es new bone and
International Journal Of Care Of The Injured, Volume 36, Issue 3, Supplement, Pages S13-S19 (November 2005)
25. • The success of t he t echnique may be
at t ribut ed t o:
High vascularit y of t he graf t ,
Single surgical sit e -- pat ient
comf ort ,
Reduced int ra-operat ive t ime
Minimum post operat ive
complicat ions, and t he low cost
• Thus, t he described t echnique
eliminat es all of t he drawbacksA. Mahajan, J Periodontol 2010;81:1426-1431.
26. This t echnique has cert ain limit at ions
• Alt hough appears simple, needs surgical
dext erit y on t he part of operat or,
especially during t he lif t ing up of t he
periost eum, which is f irmly adherent t o
t he underlying bone.
• Also, t he long t erm complicat ions of
t he t echnique, such as t he pot ent ial f or
27. CONCLUSIONS
• Alt hough only a f ew cases were t r eat ed using
t he PPG, t he r esult s ar e encour aging.
• Fur t her st udies t hat compar e t he r esult s of
t his t echnique wit h alr eady est ablished
t echniques ar e necessar y t o suppor t it s
regular use.
28. Acknowledgements
• Dr . Vij ay K Chava
• Dr . B.V Ramesh Reddy
• Dr . K. Sir isha
• Dr . J immly J ames
