49. Mucogingival therapy and plastic periodontal surgery - methods for root coverage.

Question 1

Main indications for root coverage procedure

Answer 1

• Aesthetic demands
• Root sensitivity
• Changing topography of marginal soft tissue to facilitate plaque control

Question 2

Gingival recession classification according to Miller

Answer 2

• Class I=>Marginal tissue recession not extending to mucogingival junction, w/ no loss of interdental bone or soft tissue
• Class II=>Marginal tissue recession extends to or beyond mucogingival junction, w/ no loss of interdental bone or soft tissue
• Class III=>Marginal tissue recession extends to or beyond the mucogingival junction=>
• w/ loss of interdental bone or soft tissue apical to cementoenamel junction (CEJ) but coronal to extent of marginal tissue recession
• Class IV=>Marginal tissue recession extends beyond mucogingival junction=>
• w/ loss of interdental bone extending to level apical to extent of marginal tissue recession

Question 3

Preparatory steps taken before attempting root coverage

Answer 3

• Root debridement
• Root planing
• Polishing surface w/ rubber cup and polishing paste
• Root surface demineralization agents=> remove smear layer

Question 4

Pedicle soft tissue grafts used for root coverage

Answer 4

• Grouped into=>
• Rotational flap procedures
• Advanced flap procedures

Question 5

Rotational flap procedure

Answer 5

• Reverse bevel incision along soft tissue margin of defect
• Dissected pocket epithelium removed, and root surface curetted
• Superficial incision made 3 mm from wound edge=>extends from gingival margin to 3 mm apical of defect=>
• Removing epithelium and outer connective tissue
• A tissue flap prepared from adjacent area by incision and sharp dissection=>
• Creates split-thickness flap
• Releasing incision placed more apically to avoid tearing
• Flap rotated 45° over recipient bed and sutured in place

Question 6

Advanced flap procedure

Answer 6

• Mucosal flap raised beyond mucogingival junction stretched coronally covering exposed root
• Two apically diverging vertical releasing incisions=>mesial and distal to tooth=>
• Connected by intracrevicular incision
• Split-thickness flap prepared, and periosteum incised releasing tension
• Tissue flap pulled coronally, adjusted for optimal fit, and secured at level of the CEJ w/ sutures.
• Additional lateral sutures placed to close releasing incisions

Question 7

Free soft tissue grafts, and how they used in root coverage

Answer 7

• Grouped into=>
• Epithelial grafts
• Connective tissue grafts
• Usually=>hard palate mucosa

Question 8

Epithelial graft

Answer 8

• Exposed root surface scaled and planed before making incisions
• 3-4 mm wide connective tissue bed prepared apical and lateral to defect
• Horizontal incisions at level of CEJ in interdental tissue on each side of tooth=>
• Followed by vertical incisions 4-5 mm apical to recession=>connected by split incision
• Template of graft made from foil, and 2-3 mm thick graft dissected from donor area
• Graft secured and sutured in place, w/ sutures maintained for 2 weeks

Question 9

Connective tissue graft

Answer 9

• Graft placed directly over exposed root=>
• Mucosal flap mobilized coronally or laterally to cover it
• Less invasive and provide improved aesthetics
• Harvesting of graft=>
• Envelope and tunnel technique

-Compared to epithelial grafts less invasive

Question 10

Healing process for grafts in root coverage procedures

Answer 10

• Fibrous organization between graft and recipient bed within two days.
• Revascularization beginning after 2-3 days
• Complete healing occurring after 10-16 weeks