Davidson Mucogingival

Question 1

Define the term “mucogingival problem”

Answer 1

Mucogingival defect is a deformity that involves the MGJ and its relationship to the gingiva, alveolar mucosa, frenums, muscle attachments and floor of the mouth.
Rose & Mealey discuss it as “triad” of gingival inflammation, soft tissue recession, and no attached gingiva in combination

Question 2

What is pseudorecession

Answer 2

“appearance” of the gingival margin of adjacent teeth at different levels, even when there has been no apical movement of the gingival margins below the CEJ
(eg usu as a result of malocclusion)

Question 3

What is the etiology of marginal gingival recessions

Answer 3

Periodontitis
Abrasive and traumatic toothbrushing habits
Thin tissue biotype in tooth positioned buccally or moved labially during ortho tx thru a thin B osseous plate leading to dehiscence through a thin gingival tissue
Frenum and muscle attachments that encroach on the marginal gingiva
Factitious lesions from patient habits

Question 4

Original rational for mucogingival surgery was predicated on the assumption that a minimal width of attached gingiva was required to maintain periodontal health.
Name 2 studies (authors) that challenge that assertion

Answer 4

Wennstrom, Lack of association btwn width of attached gingiva and the development of soft tissue recession
Miyasato, Gingival condition in areas of minimal and appreciable width of KT
Kennedy, Longitudinal evaluation of varying widths of attached gingiva

*basically studies showed that in the presence of good OH and plaque control, there was no min KT required

Question 5

Indications for surgical treatment of recessions

Answer 5

Progressive recession
Patient sensitivity (after conservative procedures attempted)
Patient concern about esthetics

Question 6

What factors can affect root coverage

Answer 6

Interproximal bone loss
Malocclusion (crowding)
Type of defect (width and extent --> wide and deep is hardest)
Thickness of the residual KT
Adequate vascular supply
Flap tension
Poor plaque control
Smoking

Question 7

What is creeping attachment? How much creep should one expect from a FGG and from a CTG?

Answer 7

Creeping = postop migration of the FGM in a coronal direction over portions of a previously denuded root
Range = -.38-1.61mm, w/ an avg = 0.89mm/yr (Bell & Valluzo 1978)

Harris found that at 13wks, he had 97.1% root coverage w/ CTG…and at 2+yrs, he had 98.4% root coverage

Question 8

Name the procedures that will widen the zone of attached gingiva (increase the width and thickness)

Answer 8

Any procedure (either masticatory or CT in origin) will increase width and thickness of the zone of attached gingiva
Tarnow's semilunar was only for root coverage --> so would not be included

Question 9

Connective tissue determines how the overlying epithelium differentiates (Karring 1975). Your patient presents with
an area of recession. There is only alveolar mucosal tissue apical recession. A CTG is planned. The existing soft tissue will be utilized to cover the graft and provide a secondary blood supply.
10 wks postop, what type of tissue should one expect to be covering the root?

Answer 9

Alveolar mucosa of the covering flap

Question 10

What are the benefits of CTG over masticatory graft

Answer 10

Color match to the surrounding tissues (esthetics)

Question 11

Where on average is the neurovascular bundle on the palate in an individual with a high palate? Low or flat palate?

Answer 11

(Reiser, IJPRD 1996)
Avg distance of the neurovascular bundle to the CEJ of the max premolars and molars = 12mm
High palate = 17mm
Shallow palate = 7mm

Question 12

Stages of healing of a FGG

Answer 12

Sullivan and Atkins
“Penne ala VOdka”

0-2 days: plasmatic circulation
2-8 days: vascularization
4-10 days: organic union

Question 13

Describe the pouch and tunnel techniques and their advantages over the Langer & Langer (1985) technique

Answer 13

TUNNEL:
CTG placed in a split thickness multienvelope recipient bed (supraperiosteal bed under a pedicle flap w/ no vertical incisions)
PTF sulcular incision made to preserve the papillae by undermining the tissue coronal to the CEJ and beyond the MGJ (sulcular incision should extend beyond the mucogingival line without raising the papillae)
PTF dissection is extended laterally through the papillae between the treated teeth without severing them. The incision must be extended 3-5 mm M and D from the lateral teeth to allow space for the graft. Donor tissue area usually extends from the distal aspect of
the canine to the most distal aspect of the tuberosity. Graft is placed into the tunnel
and secured w/ sutures.
Mild compression with a sterile gauze with
saline for 5 min
Indications: multiple adjacent recessions, situations in which very early healing is needed for esthetic demands, need to reduce the number of surgical interventions.

POUCH:
Usually for one tooth (vs tunnel for multiple sites)
Pouch is created with a very small blade 15C or Beaver, under the adjacent papilla.
May extend 10-12 mm apical to the recessed gingival margin and 6-8 mm mesial and distal to the denuded root surface
Advantages: minimize incisions and reflection of flaps, provides intimate contact of the donor tissue to the recipient site.

Question 14

Where on the palate should one obtain a FGG? What are the anatomical concerns in obtaining a masticatory graft.

Answer 14

From areas posterior to the rugae, from an edentulous site, or from a wide tuberosity
Anatomical concerns: neurovascular channels, greater palatine foramina, and the rugae

Question 15

Where on the palate should one obtain a CTG? What are the anatomical concerns

Answer 15

(palate) from the mesial of the 1st molar to the area of the cuspid
Anatomical concerns: greater palatine artery and nerve

Question 16

Describe Miller’s classification system

Answer 16

Class I- Marginal tissue recession which does not extend to the MGJ.
There is no periodontal loss (bone or soft tissue) in the interdental area
100% root coverage can be anticipated

Class II-Marginal tissue recession which extends to or beyond the MGJ.
There is no periodontal loss (bone or soft tissue) in the interdental area
100% root coverage can be anticipated

Class III- Marginal tissue recession which extends to or beyond the MGJ.
Bone or soft tissue loss in the interdental area is present or there is malpositioning of the
teeth which prevents the attempting of 100% root coverage.
Partial root coverage can be
anticipated

Class IV- Marginal tissue recession which extends to or beyond the mucogingival junction.

Question 17

Photo shown of pt with marginal inflammation in lower anterior and soft tissue recession. No loss of proximal bone.
Classify this recession using both classification systems

Answer 17

Miller I or II (probe was not shown in place)

Sullivan and Atkins - shallow wide

Question 18

What are the benefits and limitations of GTR therapy in the treatment of recession?

Answer 18

BENEFITS
1 surgical site
increased gain in clinical attachment and reduction in probing depth
(Jepsen 1998) GTR technique and the CT graft had equal gain of clinical attachment and root coverage after 12 months,
May also reconstruct the lost attachment apparatus along with covering the denuded root surface

LIMITATIONS-
space for the membrane,
adequate thickness of overlying soft tissue (1 mm. thickness),
exposure of the membrane if a nonresorbable barrier is utilized

Question 19

What is acellular dermal matrix and what are the advantages of its use?

Answer 19

This allograft is freeze dried, cell free, dermal matrix comprised of a structurally integrated basement membrane complex (BMC) and extracellular matrix in which collagen bundles and elastic fibers are the main components.

Advantages-surgical procedure does not require a second site to obtain donor material, high level of success of root coverage (74% success, 90% of the time)

Question 20

What procedures have the highest predictability for 90% root coverage.

Answer 20

(AAP Academy Report 2005)

ADM + CPF = 86%