This document discusses mucogingival surgery techniques used to correct problems related to attached gingiva, shallow vestibules, and aberrant frenums. It describes free gingival autograft procedures which involve taking a graft of tissue from the palate and suturing it to the recipient site to widen the attached gingiva. The healing process is discussed where the graft undergoes revascularization over 10-16 weeks as new blood vessels and epithelium develop. Variations on the free gingival autograft technique include the accordion and strip methods.
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2. CONTENTS
INTRODUCTION
OBJECTIVES
PROBLEMS ASSOCIATED WITH ATTACHED GINGIVA , SHALLOWVESTIBULE,
ABERRANT FRENUM
TECHNIQUE TO INCREASE THE ATTACHEDGINGIVA
GINGIVALAUGMENTATIONAPICALTO THEAREAOF RECESSION
GINGIVALAUGMENTATION CORONALTO THEAREAOF RECESSION
TECHNIQUES FOR ROOT COVERAGE
TECHNIQUES TO DEEPEN THE VESTIBULE
TECHNIQUES TO REMOVE THE FRENUM
3. INTRODUCTION
Mucogingival surgery - surgical procedure for the correction of relationships
between the gingiva and the oral mucous membrane with reference to three
specific problemareas:
i) attached gingiva
Ii) shallow vestibule
Iii) frenum interfering with the marginal gingiva
1996 WWP -renamed mucogingival surgery as Periodontal Plastic Surgery.
4. This term was proposed by Miller in 1993 and included the following areas:
Periodontal-prosthetic corrections
Crown lengthening
Socket preservation
Ridge augmentation
Esthetic surgical corrections
Coverage of the denuded root surfaces
Reconstruction of papillae
Esthetic surgical correction around implants
Surgical exposure of unerupted teeth for orthodontics.
5. Periodontal plastic surgery - surgical procedures performed to correct or
eliminate anatomic, developmental or traumatic deformities of the gingiva or
alveolar mucosa.
Mucogingival therapy is a broader term that includes the non-surgical
procedures such as papilla reconstruction by means of orthodontic or restorative
therapy.
7. To treat muco - gingival problems
Inadequate width of attached gingiva
Class II, III and IV gingival recession
Shallow vestibule
High frenal attachment (papillary and papilla penetrating)
Pockets extending beyond mucogingival junction
Objectives
8. PROBLEMS ASSOCIATED WITH ATTACHED GINGIVA
Difficulty in removal of plaque and maintaining oral hygiene
Esthetic problems due to gingival recession
Inflammation around restored teeth
9. PROBLEMS ASSOCIATEDWITH SHALLOW VESTIBULE
Gingival recession - gingival margin apically - vestibular depth.
With minimal vestibular depth, proper hygiene procedures are
jeopardized.
The sulcular brushing technique requires the placement of the
toothbrush at the gingival margin which may not be possible with
reduced vestibular depth.
10. Minimal attached gingiva with adequate vestibular depth may not
require surgical correction if proper atraumatic hygiene is
practiced.
Minimal amount of keratinized attached gingiva with no vestibular
depth benefit from mucogingival correction.
Removable prostheses - Adequate vestibular depth is necessary
11. PROBLEM ASSOCIATED WITH ABERRANT FRENUM
A frenum that encroaches the marginal gingiva - interfere with the plaque removal,
and the tension on the frenum may tend to open the sulcus.
Correction of the frenal or muscle attachments should be done that extend coronal to
the mucogingival junction.
If adequate keratinized attached gingiva is present coronal to the frenum - not
necessary to remove the frenum
12. ESTHETIC DEFORMITIES
The presence of the interdental papilla is also important to satisfy the
esthetic goals of the patient.
A missing papilla creates a space referred as blackhole.
13. An other area of concern is the patient who presents with an excessive amount of
gingiva inthe visible area, the condition addressed as gummy smile.
This may be corrected by crown lengthening.
Also gingival asymmetry needs to be corrected to improve the smile profile of the
patient.
14. Factors than can affect outcome of the treatment
Irregularity of teeth
Orthodontic correction is indicated when the mucogingival surgery is
performed on malposed teeth in an attempt to widen the attached gingiva or to
restore the gingiva over denudedroots.
If orthodontic treatment is not feasible, the prominent tooth should be reduced
to within the borders ofthe alveolar bone.
15. GINGIVAL
AUGMENTATION
CORONAL TO THE AREA
OF RECESSION(ROOT
COVERAGE)
Techniques to increase attached gingiva
GINGIVAL
AUGMENTATION
APICAL TO THE
AREA OF
RECESSION
16. GINGIVALAUGMENTATIONAPICAL TO
RECESSION
FREE GINGIVALAUTOGRAFT
Free gingival grafts are used to create a widened zone of attachedgingiva
which as initially described by Bjorn in 1963.
17. THE CLASSIC TECHNIQUE
STEP 1: PREPARE THE RECIPENT SITE
Prepare a firm connective tissue bed to receive a graft.
Using a no. 15 surgical blade the recipient site is prepared by incising the existing
mucogingival junction to the desired depth.
Extend the incision to approximately twice the desired width of the attached
gingiva allowing for 50% contraction of the graft when the healing is complete.
The periosteum is sometimes penetrated in an effort to prevent post-
operative narrowing of the attached gingiva.
19. STEP 2: Obtain the graft from donor site
Graft is usually obtained from palate
The graft should consist of epithelium and a thin layer of underlying
connective tissue.
Transfer a piece of keratinized gingiva approximately the size of the
recipient site.
Place the template over the donor site
21. Proper thickness is important for survival of the graft
The ideal thickness of a graft is between 1.0 and 1,5 mm.
A graft that is too thin may necrose and expose the recipient site.
If the graft is too thick, its peripheral layer is jeopardized because of
the excessive tissue that separates it from new circulation and
nutrients.
23. Step 3: Transfer and Immobilize the Graft:
Remove the sponge from the recipient site; reapply it, with pressure if necessary,
until bleedingis stopped.
Remove the excess clot.
Position the graft and adapt it firmly to the recipient site.
Suture the graft at the lateral borders and to the periosteum to secure it inposition.
Tissue forceps should be used delicately and a minimum number of sutures used to avoid
unnecessary tissue perforation.
25. Step 4: Protect the Donor Site:
Cover the donor site with a periodontal pack for 1 week, and repeat if necessary.
Retention of the pack on the donor site can be a problem.
A modified Hawley retainer is useful to cover the pack on the palate and over
edentulousridges.
26. VARIANTTECHNIQUES
Variants to the classic technique include the
i) accordion technique,
ii) strip technique, and
iii) combination of both
All are modifications of the free grafts:
The accordion technique, described by Rateitschak et al attains expansion
of the graft by alternate incisions in opposite sides of the graft.
28. The strip technique, developed by Han et al., consists of obtaining two or three 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 pack.
The advantages of this technique are the rapid healing of the donor site.
The donor site usually does not require suturing and heals uneventfully in 1 week.
30. HEALING OF THE GRAFT
Fibrous organization of the interface between the graft and the recipient bed
occurs within 2 to several days.
The graft is initially maintained by a diffusion of fluid from the host bed, adjacent
gingiva, and alveolar mucosa.
The fluid is a transudate from the host vessels and provides nutrition and
hydration essential for the initial survival of the transplanted tissues.
31. During the first day, the connective tissue becomes edematous and disorganized
and undergoes degeneration and lysis of some of its elements.
As healing progresses, the edema is resolved, and degenerated connective tissue
is replaced by new granulation tissue.
Revascularization of the graft starts by the second or third day.
32. Capillaries from the recipient bed proliferate into the graft to form a
network of new capillariesand anastomose with preexisting vessels.
The central section of the surface is the last to vascularize, but this is complete
by the tenthday.
The epithelium undergoes degeneration and sloughing which is replaced by
new epithelium from the borders of the recipient site.
A thin layer of new epithelium is present by the fourth day, with rete pegs
developing by theseventh day.
33. As seen microscopically, healing of a graft of intermediate thickness (0.75
mm) is complete by 10.5 weeks and thicker grafts (1.75 mm) may require 16
weeks orlonger.
The graft is pale and the pallor changes to an ischemic grayish white
during the first 2 days until vascularization begins and a pink color
appears.
Loss of epithelium leaves the graft smooth and shiny.
Functional integration of the graft occurs by the seventeenth day