BDS11007 Mucogingival Management 1 PDF

Date : / / 20 Clinical presentation of mucogingival problems Gingival enlargement Gingival recession Excessive gingival display Deformed edentulous ridge Treatment of gingival enlargement Gingivectomy Excision of the gingiva Indications: Small areas of gingival enlargement (6 teeth) Attachment loss...

Date : / / 20 Clinical presentation of mucogingival problems Gingival enlargement Gingival recession Excessive gingival display Deformed edentulous ridge Treatment of gingival enlargement Gingivectomy Excision of the gingiva Indications: Small areas of gingival enlargement (6 teeth) Attachment loss or osseous defects If gingivectomy could cause a mucogingival problem Treatment of gingival enlargement Gingivectomy Advantages: Simple & quick Disadvantages: Postoperative bleeding and discomfort Open wound/ healing secondary intention Sacrifice the keratinized tissue No chance for osseous recontouring Flap technique Advantages: Less discomfort & bleeding Healing: primary intention Postsurgical home care can be started earlier Disadvantages: Technically more gingivectomy difficult than Treatment of gingival enlargement Gingivectomy Step 1: Pocket marking Periodontal probe Crane-Kaplan Step 2: Incision on facial & lingual surfaces (Bard-Parker blades #15, 12 or Kirkland knife ) Incision is directed coronal to the tooth, beveled 45 degrees and as close as possible to the bone without exposing it Should recreate the normal festooning pattern of the gingiva Treatment of gingival enlargement Gingivectomy Step 3: Interdental incision (Orban knife) Remove the excised pocket wall, all granulation tissue and any remaining calculus Step 4: cover the area with a periodontal dressing Treatment of gingival enlargement flap technique Bone sounding Determine extent of osseous defects internal bevel incision at least 3 mm coronal to MGJ beveled 45° to the bone Orban knife: interdental incision Treatment of gingival enlargement flap technique Elevation of full thickness flap Remove granulation tissue Root surface debridement Bone recontouring Flap is replaced and sutured Sutures removed after 1 week Clinical presentation of mucogingival problems Gingival enlargement Gingival recession Excessive gingival display Deformed edentulous ridge Treatment of gingival recession Gingival augmentation Root coverage Mucogingival Surgery: any surgery designed to preserve attached gingiva. Why we need to augment the gingiva??? The “tissue barrier” concept: the keratinized attached mucosa consisting of a band of dense collagenous CT and could retard or obstruct the spread of inflammation better than the loose CT fiber arrangement of alveolar mucosa. Goldman and Cohen (1979) Treatment of gingival recession Gingival augmentation Indications for gingival augmentation Patient is experiencing discomfort during tooth brushing and/or chewing Orthodontic tooth movement is planned and is expected to cause bone dehiscence, augmenting the gingiva will decrease the risk for recession Subgingival restoration margins will be placed in thin gingival biotype Attached gingiva Gingival tissue bound to the tooth and underlying bone. From base of sulcus /or free gingival groove to the MGJ. The width of attached gingiva = subtracting the depth of the sulcus from the distance between the crest of gingival margin to the MGJ Width varies from 1-9 mm. A minimum width of attached gingiva (2mm) required to maintain gingival health and to prevent recession Gingival thickness (biotype) Thin tissue biotype: gingival thickness 2mm Methods of evaluating gingival thickness: 1. Direct measurement: periodontal probe or anesthetic needle insertion under LA 2. Transparency probe method: 3. Ultrasonic device: has many limitations 4. CBCT: visualize both soft & hard tissue Treatment of gingival recession Gingival augmentation Vestibular/gingival extension procedures 1. Denudation procedure 2. Split flap/ periosteal retention 3. Apically positioned flap Grafting procedures 1. Pedicle grafts 2. Free grafts 3. Allogenic graft acellular freeze-dried dermal matrix (ADM) human fibroblast- derived dermal substitute Treatment of gingival recession Gingival augmentation Apically positioned flap elevation of soft tissue flaps and their displacement during suturing in an apical position leaving 3–5 mm of alveolar bone denuded in the coronal part of the surgical area. Aim: to increase width of keratinized gingiva Disadvantages: bone resorption, pain Treatment of gingival recession Gingival augmentation pedicle graft Graft remains connected to donor site after placement on recipient bed better blood supply Treatment of gingival recession Gingival augmentation Free gingival graft Relocation of keratinized palatal epithelium and connective tissue from its original site to a remote donor tissue. Aim: to create a widened zone of keratinized attached gingiva Procedures: Step 1: Preparation of the recipient site Step 2: Obtain the graft from the donor site. Step 3: Transfer and immobilize the graft Step 4: Protect the donor site Treatment of gingival recession Gingival augmentation Free gingival graft Step 1: firm CT bed (recipient site) Start at MGJ 2 vertical incisions Partial thickness flap (periosteum covering the bone) Recipient bed: twice the desired width of the attached gingiva (50% contraction of the graft on healing). Flap sutured apically Treatment of gingival recession Gingival augmentation Free gingival graft Step 2: graft (donor site) Premolar zone Epithelium + thin layer of underlying CT Foil template Proper graft thickness: 1.5–2 mm Too thin graft: graft necrosis Too thick graft:  jeopardize the peripheral layer (separated from circulation & nutrients)  deeper wound at the donor site Treatment of gingival recession Gingival augmentation Free gingival graft Step 3: Transfer and immobilize the graft sponge with pressure on the graft for few minutes  Avoid “dead space” Periosteal sutures Avoid tension and trauma to the graft Step 4: Protect the donor site periodontal pack for 1 week fixing it with sutures or plastic stents to donor site Treatment of gingival recession Gingival augmentation Healing of FGG (3 phases) Initial phase (0-3 days) Thin layer of exudate Avascular plasmatic circulation close contact is mandatory Graft over avascular root surface for recession coverage → increased risk of failure survival of graft is limited by the size of the avascular area relative to the size of the vascularized graft lying on CT bed Degeneration of the epithelium of the graft Treatment of gingival recession Gingival augmentation Healing of FGG (3 phases) Revascularization phase (2-11 days) Anastomoses Capillary proliferation Fibrous union Re-epithelialization of graft the Tissue maturation phase (11-42 days) The number of blood vessels in the graft is gradually reduced till it becomes a normal circulation after 14 days The epithelium gradually matures with formation of a keratin layer Treatment of gingival recession Root coverage Indications for root coverage: Esthetic demand Root sensitivity Change the topography of the marginal gingiva for better plaque control and oral hygiene First: encourage patient to quit the traumatic tooth brushing technique and use soft tooth brush Classification of gingival recession wide narrow Miller Classification This is the most commonly used Complete root coverage can be obtained in Miller class I & II Only partial coverage is expected for class III & IV The most important clinical variable that determines the outcome of root coverage is the level of periodontal tissue support at the proximal surface Classification of gingival recession Miller Classification Class I Miller Class III Miller Class II Miller Class IV Miller Treatment of gingival recession Root coverage Root surface treatment: The exposed portion of the root should be: Free of plaque (by root planning or polishing) Extensive root planning (root prominence/shallow carious lesion) fillings on the root Root surface demineralization:  Remove the smear layer  new fibrous attachment Treatment of gingival recession Root coverage 1. Pedicle soft tissue grafts According to the direction of transfer: a) Rotational flap (lateral sliding flap/ double papilla flap) b) Advanced flaps (coronally repositioned flaps/ semilunar repositioned) coronally 2. Free soft tissue grafts a) Epithelialized grafts (free gingival graft) b) Non epithelialized graft (subepithelial CT graft) Selection of treatment procedure depends on: Depth & width of the recession / Availability of donor tissue / muscle attachment and depth of the vestibule / Esthetics Root coverage pedicle grafts (laterally positioned flap) Indications isolated, denuded root surfaces Narrow recession Adequate interdental bone height Adequate donor tissue laterally (adequate keratinized tissue width and thickness) No fenestration or dehiscence at the donor site Deep vestibule Root coverage pedicle grafts (laterally positioned flap) Advantages: one-stage procedure Sufficient blood supply. Color blend and root coverage are excellent in well-chosen cases. Root coverage pedicle grafts (double papilla flap) Indications: wide Interdental papilla adjacent to the recession. No Periodontal pockets. laterally positioned flap can’t be performed. Disadvantages: suturing the two flaps over the root surface Unpredictable results. Root coverage pedicle grafts (coronally positioned flap) purpose: split-thickness flap positioned coronally to cover the root. Isolated deep recession Root coverage pedicle grafts (coronally positioned flap) 1 step procedure sufficient zone of keratinized tissue apical to the recession CAF performed in a single step with or without SCTG according to the gingival biotype Double step procedure insufficient zone of keratinized gingiva 1st: gingival augmentation by FGG to 2nd: after 2 months CAF to cover the recession Root coverage pedicle grafts (semilunar coronally positioned flap) Advantages: no disturbance of the adjacent papillae no shortening of the vestibule no tension on the flap. Sometimes no sutures are needed. Indications: 3 mm from gingival margin Sulcular partial thickness incision to Thick gingival phenotype. reach semilunar successful in maxilla / not recommended in advanced coronally Shallow recession/ not extensive (3 mm) mandible Root coverage free gingival graft Two steps: Gingival augmentation 2 months later CAF 1 step procedure FGG to cover the recession graft should lie on 3-4 mm CT bed for graft vascular supply 2 Horizontal incisions / 2 vertical incisions Split thickness flap periosteal sutures Disadvantages Color mismatch Root coverage free subepithelial connective tissue graft CT carries the genetic message for the overlying epithelium to become keratinized. Advantages Donor site: Primary closure/ healing is by first intention. Better double blood supply better color match & esthetics for gingival augmentation and/ or gaining root coverage. Root coverage free subepithelial connective tissue graft Harvesting techniques Site: Palate maxillary premolars and 1st molar area Avoid the second molar area to avoid injury to the greater palatine artery Envelope / L-shaped / trap door Horizontal incision 2-3 mm apical to the soft tissue margin Summary Treatment of gingival enlargement: Gingivectomy Flap technique Indications / contraindications/ advantages/ disadvantages Treatment of gingival recession: Gingival augmentation: Indications for gingival augmentation / attached gingiva / gingival phenotype Vestibular gingival extension ……. Apically positioned flap Grafting procedures Pedicle grafts (laterally positioned) Free grafts…………….free gingival graft (steps/ 3 phases of healing) Summary Root coverage: Indications for root coverage Miller’s Classification of gingival recession Root surface treatment Pedicle grafts (lateral / double papilla/ coronally advanced/ semilunar) Free soft tissue grafts (free gingival graft/ subepithelial CT graft) READING MATERIAL Carranza`s clinical periodontology, Newman, Takei, Klokkevold, Carranza (Chapter 58) Clinical periodontology and implant dentistry, Jan Lindhe and Niklaus P. Lang, volume 2 (chapter 46)