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.
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.
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 2. What is gingival recession. Give etiology, classification and different surgical method of management of it and describe any one in detail.
Answer.
Different Surgical Methods of Management of Gingival Recession
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
- Widening of attached keratinized gingiva either apical or coronal to area of recession which is accomplish by various techniques
- Free gingival autograft
- Free connective tissue autograft
- Apically positioned flap
Subepithelial Connective Tissue Graft
Proposed by “Langer and Langer” in 1985.
Indications
- Where esthetic is of prime concern.
- For covering multiple denuded roots.
- In the absence of sufficient width of attached gingiva in the adjacent areas.
Connective Tissue Graft Advantages
- High degree of cosmetic enhancement
- One step procedure
- Minimal palatal trauma
- Increased graft vascularity
Connective Tissue Graft Disadvantages
- High degree of technical skills required
- Complicated suturing.
Connective Tissue Graft Technique
Step 1—Incisions and flap reflection: Raise a partial thickness flap with a horizontal incision 2 mm away from the tip of the papilla and two vertical incisions 1-2 mm away from the gingival margin of the adjoining teeth. These incisions should extend at least one half to one tooth wider mesiodistally than the area of gingival recession. Extend the flap to the mucobuccal fold without perforations that could affect the blood supply.
Step 2—Scaling and planning: Thoroughly scale and plan the root surface, reducing any prominence of the root surface.
Step 3—Obtaining the graft: From the palate, obtain connective tissue graft by means of a horizontal incision 5-6 mm from the gingival margin of molars and premolars. The connective tissue is carefully obtained and all adipose and glandular tissues are removed. The donor site is sutured after the graft is removed.
Step 4—Transferring the graft: Place the connective tissue on the denuded root. Suture it with resorbable sutures to the periosteum. Good stability of the graft must be attained with adequate sutures.
Step 5—Suturing: Cover the graft with the outer portion of the partial thickness flap and suture it interdentally. At least one-half to two-thirds of the connective tissue graft must be covered by the flap for the exposed portion to survive over the denuded root.
Step 6—Covering the graft: Cover the grafted site with dry aluminum foil and periodontal dressing. After 7 days, the dressing and sutures are removed.
Question 3. What are indication for mucogingival surgery. Describe briefly management of gingival recession.
Or
Define and classify gingival recession. Write in detail different treatment options for gingival recession.
Answer.
Indications for Mucogingival Surgery
- Augmentation of the edentulous ridge.
- Crown lengthening.
- Prevention ridge collapse associated with tooth extraction.
- Loss of interdental papilla which presents as esthetic/phonetic defect.
Management of Gingival Recession
Gingival Augmentation Apical to Area of Recession
A graft either pedicle or free is placed in a recipient bed apical to the recessed gingival margin. No attempt is made to cover the denuded root surface where there is gingival or bone recession. So, following are the procedures to augment gingiva apical to recession:
- Free epithelial autograft
- Free connective tissue autograft
- Apically positioned flap
- Fenestration
- Vestibular extension.
Free Epithelial or Gingival Autograft
- They create wide zone of attached gingiva.
- Their main objective is to increase zone of attached gingiva.
- Its secondary objectives are root coverage and vestibular deepening.
- Procedures for free gingival autograft are classical technique and variant techniques.
Classical technique
Step 1: Elimination of pockets
- If pockets are present eliminate them by resection with gingivectomy incision. Also, do the scaling and planing of root surfaces.
- If pockets are absent gingival margin should be left intact.
Step 2: Preparation of recipient site
There are two techniques for preparation of recipient site:
- First technique: Incise at existing mucogingival junction with No. 15 BP blade to a little more than desired depth and blending the incision over both ends with mucogingival line. Periosteum is left covering the bone.
- Second technique: Recipient site should be outlined by two vertical incisions from cut gingival margin to oral mucosa. Excision should be extended to desired width of attached gingiva. A no. 15 blade is inserted along cut gingival margin and separates a flap consists of connective tissue and epithelium without disturbing periodontium. Flap should be sutured where apical portion of free gingival graft will be located.
- Tin foil template should be adapted at the recipient site.
Step 3: Obtaining graft from donor site
- Partial thickness of graft is used, sites from which it is obtained are attached gingiva, masticatory mucosa from edentulous ridge and palatal mucosa.
- Graft should consist of epithelium as well as thin layer of underlying connective tissue.
- Tin foil template should be placed at donor site and a shallow incision is made over it from no. 15 blade.
- Blade is inserted to the optimal thickness at one edge of graft and is elevated by holding with tissue forcep or sutures are placed at margin of graft. Ideal thickness of the graft should be between 1 and 1.5 mm.
- As graft is separated, loose tissue tags are removed from the under surface.
Step 4: Transfer and immobilization of the graft
- Remove the excess clot from the recipient site because thick clot interfere with vascularization of graft.
- Graft is immediately transferred to the recipient site and immobilized by suturing to the periosteum of adjacent attached gingiva with adequate number of restorable sutures.
- Exert pressure against the graft for a few minutes to eliminate thick blood clot between the graft and recipient bed.
Step 5: Protection of the donor site
- Cover the donor site with a periodontal pack for 1 week and repeat if necessary.
- Modified Hawley’s retainer is useful to cover the pack on the plate and cover the edentulous ridges.
Variant technique procedure
Accordion Technique
Expansion can be achieved by giving alternate incisions on the opposite sides of the graft.
Strip technique
- The strip technique by Han and associates consists of 2 or 3 strips of tissue about 1 mm wide and long enough to cover the entire length of the recipient site.
- These strips are placed at the center and base of the recipient site and sutured from the oral mucosa. The area is then covered with tinfoil and a surgical pack.
Combination techniques
It can be performed as follows:
- Remove a strip of tissue about 3–4 mm thick from the palate, place it between two wet tongue depressors, and slice it longitudinally with a sharp BP blade.
- Use a superficial portion that contain epithelium and connective tissue, and the deeper portion that only consist of connective tissue.
Free Connective Tissue Autograft
This method is based on the fact that connective tissue carries the genetic message for the overlying epithelium to get keratinized. So, only the connective tissue from keratinized zone is used as a graft.
Apically Positioned Flap
It is used for combining purposes of eliminating pockets and widening the zone of attached gingiva. It either uses full thickness or partial thickness flap to avoid exposure to bone.
Procedure
- Step 1: Internal bevel incision 0.5–1 mm is given from crest of marginal gingiva.
- Step 2: Crevicular incision and interdental incisions are given
- Step 3: Vertical incisions extend beyond the mucogingival junctions are made so that the flap can be displaced easily. Reflect the flap depending on the purpose.
- Step 4: Debride the area and place the flap apical to its original position and suture.
Fenestration
Fenestration operation utilizes a partial thickness flap, except in rectangular area at base of the operative field where the periosteum is removed, exposing the bone. This is the area of fenestration and its purpose is to create a scar which is firmly bound to bone.
The results obtained are not as predictable as those obtained with the free gingival graft or apically displaced flap.
Vestibular Extension
- The operative field is outlined by two vertical incisions from the junction of the marginal and attached gingiva to approximately 12 mm from the alveolar margin into the vestibule.
- The vertical incisions are joined by horizontal incision.
- A mucosal flap is elevated exposing periosteum on the bone.
- The periosteum is separated starting from the bone, starting from the line of attachment of the mucosal flap.
- The periosteum, including muscle attachments is transported to bone and is sutured to the inner surface of periosteum.
- The periosteum is then transported to the lip and is sutured where the horizontal incision was made.
Gingival Augmentation Coronal to Recession (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.
Lateral Pedicle 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 onto 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.
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 1.0 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.
Guided tissue tegeneration
Step 1: A full thickness flap is raised up to the mucogingival junction. Partial thickness flap is raised at least 8 mm apical to the mucogingival junction.
Step 2: The root surface is meticulously planed and a Gore-tex membrane is trimmed awarding to the size of the defect and tried to the tooth. Make sure that it covers at least 2 mm of marginal periosteum.
Pass a suture through the membrane, that covers the bone and this suture is knotted on the exterior and tied to bend the membrane, so that a space is created between the root and the membrane.
Step 3: Flap is then positioned coronally and suture four weeks later, the membrane is carefully removed.
Pouch and Tunnel technique
Both free gingival and connective tissue autograft are used for the apical widening and can be used for coronal augmentation by incorporating some modifications
Question 4. Write indication, contraindication and objectives of mucogingival surgery.
Answer. Mucogingival surgery “Periodontal surgical procedures designed to correct defects in the morphology, position and/or amount of gingiva.” —Periodontal Literature reviews
- Done to Correct Mucogingival Problems
- Pocket existing up to or beyond mucogingival junction.
- Recession causing denudation of root surfaces.
- High frenum and muscle attachments.
- Inadequate width of attached gingiva.
Mucogingival Surgery Objectives
- Widening the zone of attached gingiva.
- Coverage of denuded roots.
- Removal of aberrant frenum.
- Creation of some vestibular depth when it is lacking.
- As an adjoined to routine pocket elimination procedure.
- Mucogingival Surgery IndicationsAugmentation of the edentulous ridge.
- Crown lengthening.
- Prevention ridge collapse associated with tooth extraction.
- Loss of interdental papilla which presents as esthetic/phonetic defect.
Mucogingival Surgery Contraindications
- In patients of advanced age.
- Patients with systemic diseases, such as cardiovascular disease, malignancy, liver diseases, blood disorders, uncontrolled diabetes, consultation with the patient’s physician is essential.
- In presence of infection.
- Where the prognosis is so poor.
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 7. Define periodontal plastic surgery. Write in detail about recession management by using free gingival graft.
Or
What do you understand by the term: periodontal plastic and esthetic surgery? Describe in detail the technique to augment gingiva apical to recession.
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.” —Carranza
Periodontal aesthetic surgery is defined as surgical procedure which deals with esthetic surgical corrections.
Techniques to Augment Gingiva Apical to Recession
So, following are the procedures to augment gingiva apical to recession:
- Free epithelial or gingival autograft
- Free connective tissue autograft
- Apically positioned flap
- Fenestration
- Vestibular extension.
Free Connective Tissue Autograft
This method is based on the fact that connective tissue carries the genetic message for the overlying epithelium to get keratinized. So, only the connective tissue from keratinized zone is used as a graft.
Apically Positioned Flap
It is used for combining purposes of eliminating pockets and widening the zone of attached gingiva. It either uses full thickness or partial thickness flap to avoid exposure to bone.
Procedure
Step 1: Internal bevel incision 0.5–1 mm is given from crest of marginal gingiva.
Step 2: Crevicular incision and inter dental incisions are given
Step 3: Vertical incisions extend beyond the mucogingival junctions are made so that the flap can be displaced easily. Reflect the flap depending on the purpose.
Step 4: Debride the area and place the flap apical to its original position and suture.
Fenestration
Fenestration operation utilizes a partial thickness flap, except in rectangular area at base of the operative field where the periosteum is removed, exposing the bone. This is the area of fenestration and its purpose is to create a scar which is firmly bound to bone.
The results obtained are not as predictable as those obtained with the free gingival graft or apically displaced flap.
Vestibular Extension
- The operative field is outlined by two vertical incisions from the junction of the marginal and attached gingiva to approximately 12 mm from the alveolar margin into the vestibule.
- The vertical incisions are joined by horizontal incision.
- A mucosal flap is elevated exposing periosteum on the bone.
- The periosteum is separated starting from the bone, starting from the line of attachment of the mucosal flap.
- The periosteum, including muscle attachments is transported to bone and is sutured to the inner surface of the periosteum.
- The periosteum is then transported to the lip and is sutured where the horizontal incision was made.
Recession Management by Using Free Gingival Graft
- One step procedure
- Classic technique—Sullivan and Atkins 1968
- Two step procedure
- Bermovin et al. 1897.
- Guinard and Coffesse 1975.
- Variant technique procedure
- Strip technique
- Accordion technique
- Combination technique.
Classical Technique
Step 1: Elimination of Pockets
- If pockets are present eliminate them by resection with gingivectomy incision. Also do the scaling and planning of root surfaces.
- If pockets are absent gingival margin should be left intact.
Step 2: Preparation of Recipient Site
There are two techniques for preparation of recipient site:
- First technique: Incise at existing mucogingival junction with No. 15 BP blade to a little more than desired depth and blending the incision over both ends with mucogingival line. Periosteum is left covering the bone.
- Second technique: Recipient site should be outlined by two vertical incisions from cut gingival margin to oral mucosa. Excision should be extended to desired width of attached gingiva. A no. 15 blade is inserted along cut gingival margin and separates a flap consists of connective tissue and epithelium without disturbing periodontium. Flap should be sutured where apical portion of free gingival graft will be located.
- Tin foil template should be adapted at the recipient site.
Step 3: Obtaining Graft from Donor Site
- Partial thickness of graft is used, sites from which it is obtained are attached gingiva, masticatory mucosa from edentulous ridge and palatal mucosa.
- Graft should consist of epithelium as well as thin layer of underlying connective tissue.
- Tin foil template should be placed at donor site and a shallow incision is made over it from No. 15 blade.
- Blade is inserted to the optimal thickness at one edge of graft and is elevated by holding with tissue forceps or sutures are placed at margin of graft. Ideal thickness of the graft should be between 1 and 1.5 mm.
- As graft is separated, loose tissue tags are removed from the under surface.
Step 4: Transfer and Immobilization of the Graft
- Remove the excess clot from the recipient site because thick clot interfere with vascularization of graft.
- Graft is immediately transferred to the recipient site and immobilized by suturing to the periosteum of adjacent attached gingiva with adequate number of restorable sutures.
- Exert pressure against the graft for a few min to eliminate thick blood clot between the graft and recipient bed.
Step 5: Protection of the Donor Site
- Cover the donor site with a periodontal pack for 1 week and repeat if necessary.
- Modified Hawley’s retainer is useful to cover the pack on the plate and cover the edentulous ridges.
Variant Technique Procedure
Accordion Technique
Expansion can be achieved by giving alternate incisions on the opposite sides of the graft.
Strip Technique
- The strip technique by Han and associates consists of 2 or 3 strips of tissue about 1 mm wide and long enough to cover the entire length of the recipient site.
- These strips are placed at the center and base of the recipient site and sutured from the oral mucosa. The area is then covered with tinfoil and a surgical pack.
Combination Techniques
It can be performed as follows:
- Remove a strip of tissue about 3–4 mm thick from the palate, place it between two wet tongue depressors, and slice it longitudinally with a sharp BP blade.
- Use a superficial portion that contains epithelium and connective tissue, and the deeper portion that only consist of connective tissue.
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 12. Define mucogingival surgery. Enumerate the different types of mucogingival surgeries and write in detail about free gingival autograft procedures.
Answer. Mucogingival surgery is defined as “surgical procedure for the correction of relationship between the gingiva and oral mucous membrane with reference to three specific problem areas: attached gingiva, shallow vestibule, frenum interfering with marginal gingiva.” Friedman
Types of Mucogingival Surgeries
- Gingival extension operation
- Free soft tissue autograft
- Classical technique
- Variant technique
- Accordion technique
- Strip technique
- Connective tissue technique
- Combination techniques
- Apically displaced flap
- Fenestration operation/Periosteal separation
- Vestibular extension operation
- Gingival augmentation coronal to recession (Root coverage).
- Conventional procedures
- Laterally displaced flap
- Double-papilla flap
- Coronally-positioned flap
- Semilunar flap.
If donor site is associated with inadequate width - Free soft tissue autograft
- Subepithelial connective tissue graft.
- Regenerative procedures
- Guided tissue regeneration.
- Conventional procedures
- Frenectomy
- Frenotomy.
Following are the free gingival autograft procedures:
Classical Technique
Step 1: Elimination of Pockets
- If pockets are present eliminate them by resection with gingivectomy incision. Also do the scaling and planning of root surfaces.
- If pockets are absent, gingival margin should be left intact.
Step 2: Preparation of Recipient Site
There are two techniques for preparation of recipient site:
- First technique: Incise at existing mucogingival junction with no. 15 BP blade to a little more than desired depth and blending the incision over both ends with mucogingival line. Periosteum is left covering the bone.
- Second technique: Recipient site should be outlined by two vertical incisions from cut gingival margin to oral mucosa. Excision should be extended to desired width of attached gingiva. A no. 15 blade is inserted along cut gingival margin and separates a flap consists of connective tissue and epithelium without disturbing periodontium. Flap should be sutured where apical portion of free gingival graft will be located.
- Tin foil template should be adapted at the recipient site.
Step 3: Obtaining Graft from Donor Site
- Partial thickness of graft is used, sites from which it is obtained are attached gingiva, masticatory mucosa from edentulous ridge and palatal mucosa.
- Graft should consist of epithelium as well as thin layer of underlying connective tissue.
- Tin foil template should be placed at donor site and a shallow incision is made over it from no. 15 blade.
- Blade is inserted to the optimal thickness at one edge of graft and is elevated by holding with tissue forcep or sutures are placed at margin of graft. Ideal thickness of the graft should be between 1 and 1.5 mm.
- As graft is separated, loose tissue tags are removed from the under surface.
Step 4: Transfer and Immobilization of the Graft
- Remove the excess clot from the recipient site because thick clot interfere with vascularization of graft.
- Graft is immediately transferred to the recipient site and immobilized by suturing to the periosteum of adjacent attached gingiva with adequate number of restorable sutures.
- Exert pressure against the graft for a few min to eliminate thick blood clot between the graft and recipient bed.
Step 5: Protection of the Donor Site
- Cover the donor site with a periodontal pack for 1 week and repeat if necessary.
- Modified Hawley’s retainer is useful to cover the pack on the plate and cover the edentulous ridges.
Variant Technique Procedure
Accordion Technique
Expansion can be achieved by giving alternate incisions on the opposite sides of the graft.
Strip Technique
- The strip technique by Han and associates consists of 2 or 3 strips of tissue about 1 mm wide and long enough to cover the entire length of the recipient site.
- These strips are placed at the center and base of the recipient site and sutured from the oral mucosa. The area is then covered with tinfoil and a surgical pack.
Combination Techniques
It can be performed as follows:
- Remove a strip of tissue about 3 to 4 mm thick from the palate, place it between two wet tongue depressors, and slice it longitudinally with a sharp BP blade.
- Use a superficial portion that contain epithelium and connective tissue, and the deeper portion that only consist of connective tissue.
Question 13. Write short note on frenectomy.
Answer. Frenectomy is defined as complete removal of frenum including its attachment to underlying bone and may be required in correction of an abnormal distema between maxillary central incisors. Carranza
Frenectomy Technique
- 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 expressed 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.
Frenectomy Indications
- In cases, where frenal attachment is close to marginal gingiva.
- In cases, where aberrant frenal attachment close to the incisive papilla leads to midline diastema.
- In cases, where aberrant frenal attachment make toothbrushing difficult in that area.
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.
Question 15. Write short note on periodontal plastic surgery.
Answer. Mucogingival surgery, term given by Friedman describe the surgical procedures for correction of relationship between gingiva and oral mucous membrane in reference to three specific problem areas, i.e. attached gingiva, shallow vestibule and frenum interfering with marginal gingiva. So along with advancement of periodontal surgical procedures, scope of nonpocket surgical procedures is increased, now encompassing multitude of areas that were not addressed in the past. Recognizing this, 1996 World workshop in clinical periodontics rename mucogingival surgery as “periodontal plastic surgery”. Periodontal plastic surgery was the term given by Miller in 1993 and is broadened to include the following areas:
- Periodontal prosthetic corrections
- Crown lengthening
- Ridge augmentation
- Esthetic surgical correction
- Coverage of the denuded root surface
- Reconstruction of papillae
- Esthetic surgical correction around implants
- Surgical exposure of unerupted teeth for orthodontics
- Periodontal plastic surgery is defined as “the surgical procedures performed to correct or eliminate anatomic, developmental or traumatic deformities of gingival or alveolar mucosa.” Carranza
- Periodontal plastic surgery includes only the surgical procedures of mucogingival therapy.
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
Indications of Periodontal Plastic Surgery
- Augmentation of edentulous ridge
- Prevention of ridge collapse associated with tooth extraction
- Crown lengthening
- Loss of interdental papilla, which present as esthetic or phonetic defect.
Question 16. Write short note on free gingival graft.
Answer. It is also known as epithelial gingival graft or free mucosal autograft.
- Free gingival graft is used to create a wide zone of attached gingiva.
- Secondary objectives are root coverage and vestibular deepening.
Free Gingival Graft Procedure
Step 1—Inject anesthesia: Adequate anesthesia is injected onto the recipient as well as donor sites.
Step 2—Prepare the recipient site: A firm connective tissue bed is prepared to receive the graft. The recipient site can be prepared by incising at the existing mucogingival junction with a 15 no. blade to the desired depth, blending the incision on both ends with existing mucogingival line. The incision is extended approximately twice the desired width of the attached gingiva which allows for 50% contraction of the graft when healing is complete.
Insert 15 no. blade along the cut gingival margin, and separate a flap consisting of epithelium and underlying connective tissue without disturbing the periosteum. The recipient bed should be smooth and essentially free of muscle attachment tissue. At this point, gauze square is packed between the wound and the lip or cheek to limit bleeding and promote hemostasis in the recipient area while the donor tissue is being obtained.
Step 3—Obtain the graft from the donor site: Donor site may be gingivectomy tissue, an edentulous ridge or the palate. The amount of donor palatal tissue needed can be accurately determined by using a foil template. Place the template over the donor site and make a shallow incision around it with a 15 no. blade. All palatal incisions are made in such a fashion so as to create a butt joint margin at the donor site. Insert the blade to the desired thickness at one edge of the graft. Elevate the edge and hold it with tissue forceps. Continue to separate the graft with the blade, lifting it gently and as separation progresses, visibility increases. A partial thickness graft consisting of epithelium and a thin layer of underlying connective tissue is used. The ideal thickness of the graft is in between 1.0 mm and 1.5 mm. Thinner graft shrivels and exposes the recipient site while thicker graft jeopardizes the circulation and nutrient diffusion.
Step 4—Transfer and immobilize the graft: Pressure is applied on the recipient site to remove the excess clot as thick clot interferes with vascularization of the graft. Suture the graft at the lateral borders and to the periosteum to secure it in position. The graft should be immobilized because any movement interferes with healing. Avoid excessive tension, which can distort the graft from the underlying surface.
Step 5—Protect the donor site: Once the graft is free, firm pressure should be applied to the donor site with a gauze square. Cover the donor site with a periodontal pack for one week and repeat if necessary. A modified Hawley retainer is useful to cover the pack on the palate.
Step 6—Postoperative instructions: Instructions to the patient are most important to the success of the graft. Patient should be advised not to brush at the recipient site for the week. Patient should not retract the lip or cheek to observe the graft. No postoperative factor will facilitate failure in soft-tissue grafting to the degree that smoking does. Smoking causes constriction of capillaries, diminished blood flow to the area, poor oxygenation of tissue causing sloughing of the graft. Thus, patient is instructed to quit smoking immediately preoperatively and abstain for the lst week (preferably for 2 weeks).
Step 7—Suture removal: Sutures are removed after 7–10 days
Healing of Free Gingival Graft
Healing of free gingival graft takes place in three steps, i.e.
- Stage of plasmatic circulation
- Stage of vascularization
- Stage of maturation
- Initially survival of the graft is by diffusion of nutrients. This is later followed by proliferation of new blood vessels from surrounding areas and establishing a plexus with the vessels which is already present in graft.
- Now this is followed by the maturation as well as functional integration which take place by 3 weeks.
- So healing includes the complete renewal of epithelium. Moreover, for many months, graft is discernable from surrounding areas.
Question 17. Define periodontal plastic surgery. Give the classification of gingival recession. Describe free gingival autograft in detail.
Or
Define periodontal plastic surgery. Define and classify gingival recession.
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.”
Gingival recession is defined as “exposure of the root surface due to apical shift in marginal gingiva”.
Classification of Gingival Recession
According to Sullivan & Atkins
- Shallow – narrow
- Shallow – wide
- Deep – narrow
- Deep – Wide
This above mentioned early classification helped to categorize the lesion but did not enable the clinician to predict the outcome of therapy. The predictability of root coverage can be enhanced by the presurgical examination and the correlation of the recession by using the classification proposed by Miller.
According to PD Miller
- Class 1. Marginal tissue recession does not extend to the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be narrow or wide.
- Class 2. Marginal tissue recession extends to or apical to the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be sub classified as wide and narrow.
- Class 3. Marginal tissue recession extends to or apical to the mucogingival junction. There is bone and soft tissue loss interdentally or malpositioning of the tooth facially.
- Class 4. Marginal tissue recession extends to or apical to the mucogingival junction. There is severe bone and soft tissue loss interdentally or severe tooth malposition.
Question 18. Define gingival recession. Classify it and write about coronally advanced flap.
Answer.
Coronally Advanced Flap
It is also known as coronally advanced tunnel technique.
- For minimizing the incisions and reflection of flaps and to provide good blood supply to donor tissue, the placement of subepithelial donor connective tissue into the pouches beneath the papillary tunnels allows for close contact of donor tissue to the recipient site. The positioning of the graft in the pouch and through the tunnel and the coronal placement of the recessed gingival margins completely covers the donor tissue. Due to this the esthetic result is excellent.
- The technique is mostly used for the anterior maxillary area where the vestibular depth is adequate and there is good gingival thickness.
- Main advantage to this technique is thickening of gingival margin as soon as healing is over. The thicker gingival margin is stable and allows the possibility of “creeping reattachment” of gingival margin.
Surgical Technique
Following is a step-by-step description of the surgical procedure as outlined by Azzi:
- Step 1: Ask the patient to follow plaque control instruction and careful scaling and root planing is to be done several weeks before starting surgical procedure. Patient should be instructed to rinse for 30 seconds with 0.l2% chlorhexidine gluconate solution.
- Step 2: After adequate anesthesia, the surgical procedure should be performed.
- Step 3: Place composite material stops at the contact points (temporary) to prevent collapse of suspended sutures inside the interproximal spaces before commencing the surgery.
- Step 4: Perform root planing of exposed root surfaces by using Gracey curettes.
- Step 5: Give initial sulcular incision by 15 c and l2 d blades. Small contoured blades and mini curettes are used for creating the recipient pouches and tunnels.
- Step 6: Over the buccal aspect, an intrasulcular incision should be given around the necks of the teeth. Extend the incision to one adjacent tooth both mesially and distally by using 15c blade. This incision maintains both height and thickness of gingival component and enables access beneath the buccal gingiva with help of Gracey curettes. Direct the cutting edge toward the bone for dissecting connective tissue beyond the mucogingival line and freed off the buccal flap from its insertions to the bone around each tooth.
- Step 7: Muscle fibers and any of the remaining collagen fibers over the inner aspect of flap, which prevent buccal gingiva from being moved coronally should be cut by using Gracey curettes.
- Step 8: Papillae should be kept intact and undermined for maintaining their integrity and carefully released from the underlying bone, which allows coronal positioning of the papillae.
- Step 9: An envelope, full thickness pouch and tunnel is created and should be extended apically beyond the mucogingival line by blunt dissection for insertion of free connective tissue graft through intrasulcular incision. Place a saline moistened gauze over the recipient site.
- Step 10: Size of the pouch, which includes the area of denuded root surface should be measured so that an equivalent size donor connective tissue can be taken from the tuberosity.
- Step 11: Create a second surgical site to obtain a connective tissue graft of adequate size and shape to be placed at recipient site. Connective tissue which is harvested from tuberosity area should be contoured to fit inside the recipient tunnel and pouch.
- Step 12: Place a mattress suture at one end of graft which help to guide the graft via sulcus and beneath each interdental papilla. Border of the tissue is gently pushed inside the pouch and tunnel by using tissue forceps and a packing instrument. The graft is pushed from adjacent tooth on one side of the surgical area to adjacent tooth over other side.
- Step 13: Place a mattress suture on one end of graft will help in maintaining the graft in position while the buccal tissue covers the connective tissue graft. This connective tissue graft is anchored to the inner inspect of buccal flap inside interdental papilla region. A vertical mattress suture is used to hold the connective tissue in position beneath the gingiva. The connective tissue graft is completely submerged beneath buccal flap and the papillae.
- Step 14: Complete gingival papillary complex (i.e., buccal gingiva along with underlying connective tissue graft and papillae) should be coronally positioned by using a horizontal mattress suture which is anchored at incisal edge of contact area. Contact areas should be splinted preoperatively to close the interdental contact by using a composite material to prevent the suture from sliding apically interdentally.
- Step 15: Other holding sutures can be placed via overlying gingival tissue and donor tissue to the underlying periosteum to secure and stabilize the donor tissue and the overlying gingiva in a coronal position.
Area should not be covered with periodontal dressing.
Patient should be instructed to rinse daily with chlorhexidine gluconate and to avoid touching the sutures during oral hygiene procedures.
Antibiotics can be administered (amoxicillin 500 mg three times a day) if seemed necessary.
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