Mucogingival Surgery In Periodontal Question And Answers

Mucogingival Surgery Periodontal Plastic Surgery

Question 1. Write short note on gingival recession.
Or
Write short note on etiology of gingival recession and its classification.
Answer. Gingival recession is defined as “exposure of the root surface due to apical shift in marginal gingiva”. Grant

Type

There are two types of recession

• Visible-clinically observable.
• Hidden-covered by gingiva.

Gingival Recession Classification

According to Sullivan and Atkins

• Shallow-narrow
• Shallow-wide
• Deep-narrow
• Deep-wide.

Read And Learn More: Periodontics Question And Answers

According to PD Miller’s

• Class 1: Marginal tissue recession that does not extend to the mucogingival junction. There is no loss of bone or soft tissue in the interdental area.
• Class 2: Marginal tissue recession that extends to or beyond the mucogingival junction. There is no loss of bone or soft tissue in the interdental area.
• Class 3: Marginal tissue recession that extends to or beyond the mucogingival junction.
  • In addition there is loss of bone and/or soft tissue in the interdental area or there is malpositioning of tooth.
• Class 4: Marginal tissue recession that extends to or beyond the mucogingival junction with severe loss of bone and soft tissue interdentally and/or severe malpositioning of the tooth.

Etiology of Gingival Recession

• Inflammatory factors
  • Plaque induced inflammatory periodontal diseases, toothbrush injury, etc.
• Anatomic factors
  • Developmental anatomic abnormalities (dehiscence, thin body plates, high frenum attachment), malocclusion.
• Iatrogenic factors
  • Deleterious habits (Pressure of foreign objects like finger nails, pencils, and hairpins)
  • Claps and mandible oral denture bars.
  • Prolonged orthodontic treatment.

Gingival Recession Clinical Significance

• Exposed root surface are susceptible to caries.
• Wearing away of cementum exposed by recession leaves an underlying dentinal hyperemia of the pulp and associated symptoms.
• In interproximal recession plaque and food debris can accumulated.

Gingival Recession Treatment

Various techniques are used to increase the width of attached gingiva:

• Gingival augmentation apical to area of recession
  • Free epithelial autograft
  • Free connective tissue autograft
  • Apically positioned flap
  • Fenestration
  • Vestibular extension
• Gingival augmentation coronal to recession or root coverage
  • Free epithelial autograft
  • Free connective tissue autograft
  • Pedicle autografts
    • Rotational, i.e. Lateral pedicle flap and double papilla flap
    • Advanced, i.e. coronally displaced flap and semilunar flap
  • Subepithelial connective tissue graft
  • Subpedicle connective tissue
  • Pouch and tunnel technique
  • Envelope technique
  • Guided tissue regeneration technique.

Question 5. Write short note on frenal problems.
Answer.

Frenum

A frenum is a fold of mucous membrane usually with enclosed muscle fibers, that attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying periosteum.

• A frenum that encroaches the margin of the gingiva may interfere with plaque removal and tensions on this frenum may tend to open the sulcus.
• In these cases, surgical removal of frenum (frenectomy) is indicated.
• High frenum attachment on the lingual surface are uncommon. To correct these without involving the structures in the floor of the mouth, approximately 2 mm of the attachment is separated from the mucosa with a periodontal knife at weekly intervals until the desired level is reached.
• The area is covered with a periodontal pack in the intervals between treatment.
• Frenectomy: It is the complete removal of frenum including its attachment to the bone. It is indicated for correction of abnormal diastema.
• Frenotomy: It is the incision and relation of the frenum to create a zone of attached gingiva between the gingival margin and the frenum.

Technique for the Removal of the Frenum (Frenectomy)

• Step 1: After anesthetizing the area, engage the frenum with a hemostat.
• Step 2: Incise along the upper surface of the hemostat, simultaneously make a similar incision along the under surface of the hemostat.
• Step 3: Remove the triangular resected portion of the frenum along with hemostat. This exposes the fibrous connective tissue attachment to bone.
• Step 4: Make a horizontal incision to dissect and separate the fibers attached to bone.
• Step 5: If needed extend the incisions laterally and suture labial mucosa to apical periosteum.
• Step 6: Clean the surgical field and pack with gauze sponges till bleeding stops.
• Step 7: Cover the area by dry aluminum foil and apply periodontal pack
• Step 8: Remove the pack after 2 weeks and repack if needed.

Question 6. Write short note on high frenal attachment.
Answer. Frenum is a fold of mucous membrane usually with enclosed muscle fibers that attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying periosteum.

In high frenal attachment the oral hygiene is hindered due to the shallow vestibule which is caused by high frenum attachment.

Frenectomy should be done for correction of high frenal attachment.

High Frenal Attachment Procedure

• Step 1: After anesthetizing the area, engage the frenum with a hemostat.
• Step 2: Incise along the upper surface of the hemostat, simultaneously make a similar incision along the under surface of the hemostat.
• Step 3: Remove the triangular resected portion of the frenum along with hemostat. This expose the fibrous connective tissue attachment to bone.
• Step 4: Make a horizontal incision to dissect and separate the fibers attached to bone.
• Step 5: If needed extend the incisions laterally and suture labial mucosa to apical periosteum.
• Step 6: Clean the surgical field and pack with guaze sponges till bleeding stops.
• Step 7: Cover the area by dry aluminum foil and apply periodontal pack.
• Step 8: Remove the pack after 2 weeks and repack if needed.

Question 8. Define and classify gingival recession. Discuss various methods for root coverage of denuded roots.
Answer.

Root Coverage Procedures for Denuded Roots

• Free epithelial autograft
• Free connective tissue autograft
• Pedicle autografts
  • Rotational, i.e. Lateral pedicle flap and double papilla flap
  • Advanced, i.e. Coronally displaced flap and semilunar flap
• Subepithelial connective tissue graft
• Subpedicle connective tissue
• Pouch and tunnel technique
• Envelope technique
• Guided-tissue regeneration technique.

The following is the Step-by-step Procedure for Laterally Displaced Flap:

• Step 1: Preparation of the recipient site:
  • Make an incision, resecting gingival margin around the exposed roots. This band of marginal gingiva is removed with a sealer or curette. The exposed root surface is planed well. If granulation tissue is present along the incised edge of the gingiva, it should be removed carefully with curettes.

• Step 2: With a # l5 blade a vertical incision is made extending from marginal gingiva into the mucogingival junction. A crevicular incision is then made from the vertical incision to the defect.
  • A flap is then raised utilizing either partial thickness or full thickness reflection. However, if the gingiva is thin flap survival becomes difficult. It may sometimes be necessary to give a short oblique incision into the alveolar mucosa at the distal corner of the flap pointing more towards the recipient site. This will enable us to slide the flap laterally without excess tension at the base.

• Step 3: Transfer the flap.
  • After the flap is transferred on to the adjacent root, the flap is sutured to the adjacent gingiva and alveolar mucosa with interrupted sutures.

• Step 4 : Protect the flap and donor site.
  • Cover the surgical site with a periodontal pack and after one week the pack and sutures can be removed. Postoperatively, antibiotics are not always necessary in the normal course of treatment, but analgesics are prescribed. The flap may heal by connective tissue adhesion, or connective tissue attachment or long junctional epithelium.

The Following is the Step-by-step Procedure for Coronally Positioned Flap:

• Step 1: Make two apically-divergent vertical releasing incisions, extending from a point coronal to the cementoenamel junction at the mesial and distal line angles of the tooth and apically into the lining mucosa.

• Step 2: A split thickness flap is prepared by sharp dissection at the mesial and distal ends and is connected with an intracrevicular incision. Facially, apical to the recession, a full thickness flap is raised.
• Step 3: Once the flap is reflected the root surfaces are debrided thoroughly. Some authors have suggested the use of citric acid with a pH l.0 for conditioning the root surface.
• Step 4: At the base of the inner surface of the flap, approximately 3 mm apical to the bone dehiscence, a horizontal incision is made through the periosteum, followed by a blunt dissection into the lining mucosa to release muscle tension. Now the mucosal graft can be easily positioned coronally at the level of cementoenamel junction.

• Step 5: The flap is secured firmly with the help of interrupted sutures and additional sling sutures can be placed to maintain the flap in place. Periodontal dressing is placed to protect the wound during initial healing.

Question 9. Discuss tension test for frenum.
Or
Write short note on tension test for frenum.
Answer.

Tension Test

Tension test is done to identify whether the width of attached gingiva is adequate or inadequate.

Frenum Procedure

This is done by stretching the lip or cheek to demarcate the mucogingival line and to see for any movement of free gingival margin. If the free gingival margin moves during stretching of lips then the attached gingiva is considered to be inadequate and the tension test said to be positive and if gingival margin does not move, test is said to be negative.

Frenum Significance

• To identify mucogingival line.
• To detect any abnormal frenum.
• To know whether attached gingiva is adequate or inadequate.

Question 10. Enumerate the techniques performed to increase the width of attached gingiva. Describe any one technique.
Answer.

Enumeration of Techniques Performed to Increase Width of Attached Gingiva.

• Gingival augmentation apical to area of recession:
  • Free epithelial autograft
  • Free connective tissue autograft
  • Apically positioned flap
  • Fenestration
  • Vestibular extension.
• Gingival augmentation coronal to recession or root coverage
  • Free epithelial autograft
  • Free connective tissue autograft
  • Pedicle autografts
    • Rotational, i.e. lateral pedicle flap and double papilla flap
    • Advanced, i.e. Coronally displaced flap and semilunar flap
  • Subepithelial connective tissue graft
  • Subpedicle connective tissue
  • Pouch and tunnel technique
  • Envelope technique
  • Apically displaced flap surgery
  • Guided tissue regeneration technique
    Used for both pocket eradication and widening of zone of attached gingiva:
    • Step 1: Internal bevel incision is made 1 mm from the crest of the gingiva and directed towards the crest of the bone
    • Step 2: Crevicular incision is made followed by initial elevation of flap and than interdental incision is performed, the wedge of the tissue containing the pocket wall is removed.
    • Step 3: Vertical releasing incisions are made extending beyond the mucogingival junction and flap is elevated with a periosteal elevator.
    • Step 4: Remove all the granulation tissues, root planning is done and flap is positioned apically at the tooth bone junction.
    • Step 5: Flaps are sutured together.

Question 11. Write short note on fate of free gingival autograft.
Answer. Extent to which the connective tissue withstands the transfer to new location determines the fate of free gingival autograft.

Maintenance of graft is initially by diffusion of fluid from the host bed, adjacent gingiva as well as alveolar mucosa.

Fluid is a transudate from host vessels which serve nutrition and hydration which is necessary for initial survival of the transplanted tissues.

On the very first day connective tissue become edematous and disorganized as well as it undergoes degeneration and lysis of some of its elements. As healing commences edema is resolved and degenerated connective tissue is replaced by the formed new granulation tissue.

Revascularization of graft starts at second or third day.

Many of graft vessels degenerate and are replaced by new ones. Central part of surface is last to vascularize and this is completed at the tenth day.

Necrosed and degenerated epithelium is replaced by new epithelium from borders of recipient site.

 

Question 14. Define periodontal plastic surgery. Describe the objectives of periodontal plastic surgery and describe apically displaced flap in detail.
Answer. Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental or traumatic deformities of gingival or alveolar mucosa.

Objectives of Periodontal Plastic Surgery

• Problems associated with attached gingiva
• Problems associated with shallow vestibule
• Problems associated with an aberrant frenum
• Aesthetic surgical therapy
• Tissue Engineering

Problems Associated with Attached Gingiva

Periodontal plastic surgery leads to creation or widening of attached gingiva around teeth and implants. Width of attached gingiva is determined by subtracting depth of sulcus or pocket from distance between crest of gingival margin and mucogingival junction. Main rationale for periodontal plastic surgery on an assumption that minimal width of attached gingiva was required to maintain optimum gingival health. For improving the aesthetics, main objective is coverage of denuded root surface. This coverage also widens the zone of attached gingiva. A wide zone of attached gingiva is needed around teeth which act as abutments for fixed or removable partial dentures. Teeth with subgingival restorations and narrow zones of keratinized gingiva have high gingival scores as compared to teeth with similar restorations and wide zones of attached gingiva. Widening of attached gingiva leads to:

• Enhanced plaque removal around gingival margin.
• Improves aesthetics.
• Reduce inflammation around restored teeth.

Problems Associated with Shallow Vestibule

In this objective of periodontal plastic surgery, creation of some vestibular depth is done when there is lack of vestibular depth. Gingival recession displaces gingival margin apically and reduces vestibular depth. With less vestibular depth oral hygiene procedures are contraindicated. Minimum attached gingiva with adequate vestibular depth does not need surgical correction if proper atraumatic hygiene is practiced from the toothbrush. Less amount of keratinized attached gingiva not having vestibular depth benefit from mucogingival correction. Vestibular depth should be adequate for proper placement of removable prosthesis.

Problems Associated with Aberrant Frenum

Objective of periodontal plastic surgery is to correct frenal or muscle attachments. If adequate gingiva is present coronal to frenum there is no need to remove it surgically. Frenum which encroaches on margin of gingiva may interfere with plaque removal and tension on this frenum may tend to open the sulcus. In such cases frenum is removed surgically.

Aesthetic Surgical Therapy

Recession of the facial gingival margin causes alteration of proper gingival symmetry and results in an aesthetic problem. The inter – dental papilla is also important to satisfy the aesthetic goals of the patient. A missing papilla creates a space that many call a black hole. Regeneration of the lost or reduced papilla is most difficult goals in aesthetic periodontal plastic surgery.Another area of concern is an excessive amount of gingiva in visible area. This condition is called as a gummy smile, and this can be corrected surgically by crown lengthening. Correction of such anatomic defects has become an important part of periodontal plastic surgery.

Tissue Engineering

Future of periodontal plastic surgery will encompass the use of tissue-engineered products at the recipient site to reduce donor site morbidity. Results of numerous experimental and clinical studies support the clinician’s use of a minimally invasive approach to periodontal plastic surgery.