Mucogingival Surgery

Mucogingival Surgery

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.
• Frenectomy
• Frenotomy.

Following are the free gingival autograft procedures:

Mucogingival Surgery 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.

Mucogingival Surgery Variant Technique Procedure

Accordion Technique

Expansion can be achieved by giving alternate incisions on the opposite sides of the graft.

Mucogingival Surgery 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.

Mucogingival Surgery 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.

 

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

Contraindication and Objectives of mucogingival surgery


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.