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MUCOGINGIV
AL
SURGERY
Dr. Kaustubh S Thakare
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
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.
 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.
 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.
PERIODONTAL
PLASTIC SURGICAL
TECHNIQUES
WIDENING OF
ATTACHED
GINGIVA
DEEPENING OF
SHALLOW
VESTIBULES
RESECTION OF
THEABERRANT
FRENUM
 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
PROBLEMS ASSOCIATED WITH ATTACHED GINGIVA
 Difficulty in removal of plaque and maintaining oral hygiene
 Esthetic problems due to gingival recession
 Inflammation around restored teeth
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.
 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
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
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.
 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.
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.
GINGIVAL
AUGMENTATION
CORONAL TO THE AREA
OF RECESSION(ROOT
COVERAGE)
Techniques to increase attached gingiva
GINGIVAL
AUGMENTATION
APICAL TO THE
AREA OF
RECESSION
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.
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.
Plastic and aesthetic surgery in periodontal disease
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
Plastic and aesthetic surgery in periodontal disease
 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.
Plastic and aesthetic surgery in periodontal disease
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.
Plastic and aesthetic surgery in periodontal disease
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.
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.
Plastic and aesthetic surgery in periodontal disease
 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.
Plastic and aesthetic surgery in periodontal disease
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.
 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.
 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.
 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
Plastic and aesthetic surgery in periodontal disease

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Plastic and aesthetic surgery in periodontal disease

  • 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.
  • 6. PERIODONTAL PLASTIC SURGICAL TECHNIQUES WIDENING OF ATTACHED GINGIVA DEEPENING OF SHALLOW VESTIBULES RESECTION OF THEABERRANT FRENUM
  • 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