3 - Mucogingival/perio plastic surgery Flashcards
What step does mucogingival and perio plastic surgery fall under?
Step 3
What factors are there to consider before undertaking mucogingival surgery?
- patient
- tooth
- systemic and medical
- operator
What are the patient factors to consider for mucogingival surgery?
- OH (<20% plaque, <10% marginal bleeding)
- quality of maintenance available and access, compliance for maintenance
- ability of patient to tolerate surgery
- cost and patient acceptance
- aesthetics of site and post op recession
What are the tooth factors to consider for mucogingival surgery?
- access
- shape of defect
- prosthodontic and endodontic considerations
- tooth position anatomy (tilting, overeruption, proximity to adjacent roots, enamel pearls, root grooves)
What are the systemic factors to consider for mucogingival surgery?
- smoking = poorer outcome (absolute contraindication on NHS)
- unstable angina, uncontrolled hypertension, MI or stroke within last 6 months
- poorly controlled diabetes
- immunosuppressed patients
- anticoagulants
What are the operator factors to consider for mucogingival surgery?
- skill and experience
- additional training or specialist required
- access to tier 2 or tier 3 care
What is tier 2 vs tier 3 care?
Tier 2 = dentist with special interest
Tier 3 = specialist care
What are the general surgical approaches for periodontal treatment?
- conservative approach
- resective approach
- reconstructive approach
What is regenerative periodontal surgery?
- aims to promote regeneration of periodontal tissues that have been lost
- includes use of membranes and grafts and application of biologic agents
- aka mucogingival surgery, perio plastic surgery
What are the indications for mucogingival surgery?
- periodontitis lesions requiring reconstructive or regenerative treatment including around implants
- mucogingival deformities and poor aesthetics
- short clinical crowns
- removal of abnormal frenum
- creation of more favourable soft tissue bed pre-implant placement
Describe the difference between a full thickness flap and a split thickness flap.
- full thickness flap is cut to the periosteum and lifts the periosteum with it
- split thickness flap leaves the periosteum in situ and leaves some connective tissue behind
What is a free gingival graft?
- split thickness flap
- free means blood supply is not maintained from donor site
- placed onto recipient site (epithelium removed to leave connective tissue exposed) and sutured in place
What is a pedicle sliding graft?
- gingival margin around defect excised
- split thickness flap raised from adjacent tooth
- flap is rotate laterally to cover defect
- donor site heals by secondary intention
- blood supply is maintained to flap
What is a connective tissue graft?
- papillae are spared as gingival margin is excised and tissue undermined
- graft is harvested from palate using a window (epithelium replaced to aid healing)
- connective tissue placed into flap at margin
- coronally advanced flap sutured in place
How are infrabony defects classified?
- 1 walled
- 2 walled
- 3 walled
What biomaterials are used for guided bone regeneration?
- barrier membrane (collagen)
- DBBM (deproteinised bovine bone matrix)
- EMD (enamel matrix derivative)
What is GBR?
Guided bone regeneration
What is the function of the collagen membrane in GBR?
- epithelial cells advance and heal quicker than connective tissue
- barrier membrane prevent epithelial cells from migrating apically
- allows connective tissue to heal
What is a long junctional epithelium?
- when epithelium cells advance apically the connective tissue does not contact the root surface
- instead epithelium cells line the root surface
- overall, weakers against bacteria in the mouth and therefore SPT is vital
What is gingival recession?
- describes apical migration of gingival margin from CEJ
- does not relate to health or disease
- descriptive term of location
What is the aetiology of localised gingival recession?
- excessive toothbrushing
- traumatic incisor relationship
- habits
- anatomy (eg frenal pull or teeth out of alignment)
- orthodontic treatment
What is the aetiology of generalised gingival recession?
Periodontal disease
What is the old classification for gingival recession?
Millers 1985
What is the new classification for gingival recession?
Cairo 2012
- RT1
- RT2
- RT3
Describe RT1.
- recession type 1
- no interpromixal tissue loss
Describe RT2.
- recession type 2
- interproximal tissue loss (CEJ-base of pocket) but not as significant as mid-buccal
Describe RT3.
- recession type 3
- gingival recession associated with loss of interproximal attachment
- interproximal tissue loss (CEJ-base of pocket) worse than mid-buccal
What are the treatment options for gingival recession?
- elimination of aetiological factors
- OHI
- topical desensitising agents (for roots)
- gingival veneer
- crowns (requires wax up)
- mucogingival surgery
When is a gingival veneer indicated?
- extensive recession and interproximal bone loss
- surgery would not achieve root coverage
What is crown lengthening?
Aims to reposition the entire periodontal attachment including the alveolar bone
What are the indications for crown lengthening?
- increase required in clinical crown height to give adequate retention for restoration
- restore biologic width
- create adequate ferrule
- expose sub gingival restoration margins/secondary caries/fractures
- correction of uneven gingival contour
Describe the crown lengthening procedure.
- flap raised
- 3-4mm bone removed using surgical handpiece
- bone around root removed with hand instruments to avoid damage to root
- coe pack placed to prevent tissue creep
