Advanced surgical technique

Question 1

Indications for apically repositioned flap

Answer 1

Pocket elimination

Crown lengthening

Question 2

Disadvantages

Answer 2

Roots exposed - sensitivity and increased risk of caries

Poor aesthetics

Question 3

Stages of incision in apically repositioned flap (3)

Answer 3

Labially: inverse bevel incisions
Palatally: gingivectomy
Relieving incisions may be necessary

Question 4

Stages of raising flap, curetta and RSD in apically repositioned flap (4)

Answer 4

Raise a flap labially beyond mucogingival junction
Currettage of pocket lining
Root surface cleaning
Repositioning apically
-raise flap beyond MCJ in apical direction

Question 5

Suturing and securing the flap apically (2)

Answer 5

Sling sutures tied labially

Pack to cover palatal gingivectomy and secure flap apically

Question 6

Post-operative care and healing (3)

Answer 6

Pack and sutures for 1 week
Healing with pocket elimination
Root surface exposed

Question 7

When is frenectomy indicated? (1)

Answer 7

Occasionally indicated in patients with a prominent labial frenum attached to interdental papilla - non-surgical vs surgical management

Question 8

Outline of frenectomy procedure (4)

Answer 8

Incision around frenum
Lip incision and undermining of edges to facilitate suturing
Lip wound sutured
Coe-pack dressing over gingival wound

Question 9

When is free gingival graft indicated? (1)

Answer 9

patient with localised recession, lack of attached gingival tissues and prominent frenal attachment

Question 10

Stages of free gingival graft (4)

Answer 10

Removal of frenum and preparation of wound to receive graft
Tissue removed from palate
Acrylic palate made pre-operatively to hold coe-pack over palatal wound
Recipient site has gingival graft sutured in place

Question 11

Indications for the surgical

management of localized gingival recession (6)

Answer 11

 Continued inflammation
 Progressive breakdown
 Aesthetics
 Frenal pull
 Pocketing beyond MGJ
 Some situations when advanced restorative procedures are planned

Question 12

Techniques of the surgical

management of localized gingival recession (5)

Answer 12

 Laterally repositioned flap
 Coronally repositioned flap
 Free gingival graft followed by coronally
repositi`oned flap
 Guided tissue regeneration
 Connective tissue graft

Question 13

Gingival augmentation vs

Root coverage procedure (2)

Answer 13

Increasing band of keratinised tissue

Can cover roots once healed

Question 14

Pre-operative assessment (6)

Answer 14

 Is surgical treatment warranted?
 Is recession stable following monitoring?
 Medical and social assessment
 Tooth vitality
 Radiographic examination
 Informed consent and clinical records

Question 15

Coronally advanced procedure ***

Question 16

Overview of laterally repositioned flap (3)

Answer 16

Incisions made around the recession defect and along the gingival margin of the adjacent donor tissue.
A releasing incision is made to release the donor tissue adjacent to the site to be treated.
A part full and part split-thickness flap is raised and rotated laterally over the defect being treated.

Question 17

Coronally repositioned flap (4)

Answer 17

A full-thickness mucoperiosteal flap is raised into the base of the buccal sulcus in relation to the teeth being treated.
The flap is then moved in a coronal direction to cover the recession defect(s).
Interdental sutures and a periodontal dressing hold it in place during healing.
The procedure may be preceded by a free gingival graft if there is insufficient attached gingival tissue.

Question 18

Guided tissue regeneration - what is it? (1)

Answer 18

A GTR membrane placed during a surgical procedure

Question 19

Guided tissue regeneration examples (3)

Answer 19

Gingival recession treated with a non-resorbable (e-PTFE) membrane
Gingival recession treated using a titanium reinforced nonresorbable membrane
Gingival recession treated with a resorbable membrane

Question 20

Overview of connective tissue graft (6)

Answer 20

Horizontal incision made through the base of interdental papilla and
around teeth being treated, into ginigival crevice buccally.
Relieving incisions are made.
A split thickness flap is raised.
A flap is raised in the palate and connective tissue with an epithelial border is dissected out.
The wound is closed using sutures and the graft transferred and sutured to the recipient site.
The recipient site flap is replaced covering as much of the connective tissue graft as possible by coronal repositioning .

Question 21

Evidence base for surgical proceudures (3) *** authors and dates and ENCORE for up to date evidence

Answer 21

Guided tissue regeneration, free gingival graft, connective tissue graft and coronally advanced flap are effective in reducing
gingival recessions with an improvement in attachment levels. No single procedure superior, however connective tissue graft was statistically significantly more effective than guided tissue regeneration in recession reduction.
Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for the treatment of localised recession-type defects. In cases where both root coverage and gain in the keratinized tissue are expected, the use of subepithelial connective tissue grafts seems to be more adequate. RCTs necessary to identify possible factors associated with the prognosis of each PPS procedure. The potential impact of bias on these outcomes is unclear.
SCTGs, matrix grafts, and EMD were superior to CAF in achieving complete root coverage, but SCTGs showed the best predictability. The
impossibility of inclusion of all identified RCTs should be taken into consideration when interpreting the present findings

Question 22

Trapdoor technique (4)

Answer 22

CT graft

Harvest CT from palate by incision, secure it underneath and place buccal epithelial flap over (apically positioned)

Question 23

Envelope technique (4)

Answer 23

CT graft

Graft from palate, place and cover with buccal epithelium (apically positioned)