Download Mucogingival therapy2

Mucoginigival Therapy
• Definition:
– Mucoginigival surgery: Periodontal surgical
procedures used to correct defects in the
morphology, position, and/or amount of
gingiva (AAP Glossary).
– Techniques are used to provide a
functionally adequate zone of keratinized
attached gingiva (Friedman, 1962).
Anatomy
• Attached gingiva:
The portion of the
gingiva that is tapered,
firm, dense, stippled,
and tightly bound to
the underlying
periosteum, tooth,
and bone.
Anatomy
• Width of AG differs in different areas of the
mouth. Greatest in the incisor region (3.5-4.5 mm
in the max, 3.3-3.9 mm in the man). Least width in
the 1st premolar area (1.9 mm in the max, 1.8 mm
in the man)
Literature Review
– No standard width of keratinized attached
gingiva has been established.
– In people with good oral hygiene 1 mm or
less may be sufficient for health (Lang and
loe, 1972; Dorfman et al., 1980).
– Kirch et al (1986) and Wennstrom (1987)
have shown that even a movable marginal
tissue of alveolar mucosa can be maintained
stable over a long period of time
Literature Review
– Trauma of prosthetic treatment (Maynard
and Wilson, 1979; Ericsson and Lindhe,
1984)
– Orthodontic restoration (Maynard and
Ochsenbein, 1975; Coatoam et al., 1981)
– Frenulum pull (Gottsgen, 1954; Gorman,
1967)
– Rapidly progressing recession (Baker and
Seymour, 1976)
Literature Review
• Tissue barrier concept:
– Goldman and Cohen (1979) outlined a
“tissue barrier” concept
– They 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
keratinized attached gingiva tissue to achieve
an adequate tissue barrier (thick tissue).
Literature Review
• Wennstrom (1985) states,”A thin marginal
tissue, in particular in the absence of
underlying alveolar bone, will be at greater
risk of recession since the plaque-induced
inflammatory lesion may occupy and cause
destruction of the entire CT portion of the
gingiva”
Objectives
1- To create an adequate zone of attached
keratinized gingiva
2- To eliminate pocket that extend beyond
the mucogingival line
3- To eliminate muscle and frenulum pull
4- To deepen the vestibule
5- To cover denuded root surfaces for
esthetics or hypersensitivity
Objectives
6- To overcome the anatomic factors of
tooth position, thin alveolar housing, and
large prominent roots, which promote
dehiscence and/or fenestration
7- To minimize recession during
orthodontic movement
8- To overcome the trauma of prosthetic or
restoration requiring subgingival
placement
Objectives
9- To stabilize and maintain a healthy
mucogingival complex
10- To correct areas of progressive gingival
recession
11- To correct ridge deformities and
undercuts
Gingival Recession
• Causes (predisposing factors):
1- Minimal attached gingiva
2- Frenum pull
3- Tooth malposition
• Precipitating factors:
1- Inflammation related to plaque
2- Improper brushing
3- Iatrogenic dental care
Classification
• Sullivan and Atkins (1968)
–
–
–
–
Shallow-narrow
Shallow-wide
Deep-narrow
Deep-wide
Classification
• Miller (1985)
Class I: Marginal tissue
recession that does not
extend to the
mucogingival
junction. There is no
periodontal loss (bone
or soft tissue) in the
interdental area, and
100% root coverage
can be anticipated.
Classification
• Miller (1985)
Class II: Marginal
tissue recession that
extend to or beyond
the mucogingival
junction. There is no
periodontal loss (bone
or soft tissue) in the
interdental area, and
100% root coverage
can be anticipated.
Classification
• Miller (1985)
Class III: Marginal
tissue recession that
extend to or beyond
the mucogingival
junction. Bone or
soft tissue has been
lost from the
interdental area,
partial root coverage
can be anticipated
Classification
• Miller (1985)
Class IV: Marginal
tissue recession that
extend to or beyond
the mucogingival
junction. Sever bone
or soft tissue has been
lost from the
interdental area, root
coverage can not be
attempted.
Procedures
•
•
•
•
•
•
•
•
Free gingival grafts
Coronally positioned flap
Subepithelial connective tissue graft
Pedicle flap
Semilunar flap
Transpositional flap
CT pedicle graft
Guided tissue regeneration with
membranes
Free Gingival Graft
• Advantages
1- High degree of predictability
2- Simplicity
3- Ability to treat multiple teeth at the same time
4- Can be preformed when keratinized gingiva
adjacent to the involved area is insufficient
5- As the first step in a two-stage procedure for
attaining root coverage
6- As a single step for attaining root coverage
Free Gingival Graft
• Disadvantages
1- Two operative sites
2- Compromised blood supply
3- Greater discomfort
4- Poor hemostasis
5- Retention of graft
Free Gingival Graft
• Factors:
1- Graft thickness (1.5 mm to 2 mm is recommended)
2- Suturing techniques
3- Entrapment of a blood clot between the graft and
the roots, as well as the adjacent soft tissue recipient
bed
4- Mechanical root preparation (Sc/Rp)
5- Flattening of the root surface with Sc and Rp or
rotary instrumentation
6- Chemical root conditioning (citric acid and
tetracycline)
Free Gingival Graft
• Contraindications
1- A perceptible mismatch in color between donor
site and gingiva adjacent to recipient site
2- A lack of thick donor tissue
3- A class III or class IV recession defect
4- A root surface of excessive mesiodistal width
coupled with interproximal tissue that is too
narrow to support the blood supply
Free Gingival Graft
• Common reasons for graft failure:
– use of root coverage (prominent roots, wide
areas of root exposure)
– proper graft adaptation
– adequate transfusion of the graft
– graft movement (plasmatic diffusion)
Coronally Positioned Flap
• Indications:
– Esthetic coverage of exposed roots
– For tooth sensitivity
• Requirements:
– adequate zone of keratinized gingiva
(>3mm)
Coronally Positioned Flap
• Advantages:
–
–
–
–
treatment of multiple areas of root exposure
no need for involvement of adjacent teeth
high degree of success
even if the procedure does not work, it does
not increase the existing problem
• Disadvantage
– need for two surgical procedures if the zone
of keratinized gingiva is inadequate
Subepithelial Connective
Tissue Graft
• Advantages
1- It is predictable for obtaining root coverage
2- The technique results in good gingival color match
3- The palatal donor site is less prone to bleeding,
and healing is easier than FGG
4- The double blood supply created in this approach
is advantageous
5- The surgeon’s ability to control the thickness is
greater than is possible with the FGG
Subepithelial Connective
Tissue Graft
• Indications
1- A lack of adequate donor tissue for a lateral sliding
flap
2- The presence of root recession
3- The presence of isolated wide recession
4- The presence of multiple root recession
5- The presence of recession adjacent to an
edentulous area requiring ridge augmentation
6- The presence of recession in an area where
esthetics is often great concern
Laterally Positioned Pedicle
Graft
• Advantages:
1- One surgical site
2- Good vascularity of the pedicle flap
3- Ability to cover a denuded root surface
• Disadvantages:
1- Limited by the amount of adjacent keratinized
attached gingiva
2- Possibility of recession at the donor site
3- Dehiscence or fenestration at donor site
4- limited to one or two teeth
Laterally Positioned Pedicle
Graft
• Contraindications:
1- Presence of deep interproximal pockets
2- Excessive root prominence
3- Deep or extensive root abrasion or
erosion
4- Significant loss of interproximal bone
height
Guided Tissue Regeneration
• Advantages:
1- Does not require a secondary donor site
2- Reduce postoperative discomfort
3- The new tissue blend with the adjacent
tissue, providing a highly esthetic result
Guided Tissue Regeneration
• Disadvantages:
1- Multiple defect can not be treated at the
same surgical session
2- Root coverage is limited by the height of the
interproximal bone.
3- The necessity of membrane removal 4 to 6
weeks after the initial surgery
Guided Tissue Regeneration
• Indications:
1- To cover isolated root surface for single
tooth with wide, deep, localized recession,
5 mm in width or depth or wider and
deeper
2- For areas of root sensitivity