Mucogingival Surgery Perio Plastic Surgery Flashcards by sophie rosen

Friedman (Texas Dent J, 1957) described
mucogingival surgery as

plastic surgery
that concerns relations between
mucogingival tissues and attached gingiva,
alveolar mucosa, frenulum, muscle
attachment and vestibule

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AAP Parameter on Mucogingival Conditions
2000
Definition:
Clinical Features:
Common mucogingival conditions are …. Anatomical variations that may complicate the management of these conditions include …. Variations in — anatomy may be associated with mucogingival con-ditions.

Definition
Mucogingival conditions are deviations from the normal anatomic relationship between the gingival margin and the mucogingival junction (MGJ).

recession, absence or reduction of keratinized tissue, and probing depths extending beyond the MGJ
tooth position, frenulum insertions and vestibular depth
ridge

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skipped
AAP Classification 1999

AAP Classification 1999
VIII. Developmental or Acquired Deformities and Conditions
A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis
Tooth anatomic factors
Dental restorations/appliances
Root fractures
Cervical root resorption and cemental tears
B. Mucogingival deformities and conditions around teeth
1. Gingival/soft tissue recession
facial or lingual surfaces
interproximal (papillary)
Lack of keratinized gingiva
Decreased vestibular depth
Aberrant frenum/muscle position
Gingival excess
pseudopocket
inconsistent gingival margin
excessive gingival display
gingival enlargement (See LA3. and LB.4.)
6. Abnormal color
C. Mucogingival deformities and conditions on edentulous ridges
Vertical and/or horizontal ridge deficiency
Lack of gingiva/keratinized tissue
Gingival/soft tissue enlargement

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. Periodontal Biotype/Phenotype
(3)

a. Thin Scalloped
b. Thick Scalloped
c. Thick Flat

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Gingival/Soft Tissue Recession
(7)

a. Facial or Lingual Surfaces
b. Interproximal (Papillary) Severity of Recession
(Cairo RT 1,2,3)
c. Gingival Thickness
d. Gingival Width
e. Presence of NCCL/Cervical Caries
f. Patient Esthetic Concern (Smile Esthetic Index)
g. Presence of Hypersensitivity

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Gingival Excess
(4)

a. Pseudo-pocket
b. Inconsistent Gingival Margin
c. Excessive Gingival Display
d. Gingival Enlargement

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Mucogingival Deformities and Conditions Around Teeth
(7)

Periodontal Biotype/Phenotype
Gingival/Soft Tissue Recession
Lack of Keratinized Gingiva
Decreased Vestibular Depth
Aberrant Frenum/Muscle Position
Gingival Excess
Abnormal Color

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Periodontal Plastic Surgery
* How much is enough?
– Bowers 63: normal varies from — mm
– Lang and Loe 72: need – mm keratinized, – mm
attached
– Maynard and Wilson 79: –mm keratinized needed
for restorative with – mm attached
– Dorfman and Kennedy 80: less than – mm is
adequate if inflammation is controlled
– Freedman et al 99: 18 year study, less than – mm is
adequate if inflammation is controlled

1-9
2, 1
5, 3
1
1

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Esthetic Enhancement
* Providing a more esthetically
acceptable gingival form and contour
(4)

– Localized gingival recession (today’s topic)
– Localized alveolar ridge deficiency
– Excessive gingival display
– Gingival enlargement or asymmetry

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Recession definition

Apical shift of the gingival margin, associated with
attachment loss
Etiology-different conditions, pathologies

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Recession definition
* Apical shift of the gingival margin, associated with
attachment loss
* Etiology-different conditions, pathologies
(4)

– Toothbrush abrasion
– Frenal attachment
– Intrasulcular restorative margin placement*
– Orthodontics-dependent upon direction and bucco- lingual soft
tissue thickness

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Potential consequences of gingival recession
* Exposed root surface making it potentially more susceptible
to
(4)

– Root caries
– Non-carious cervical lesions (NCCL’s)
– Dentinal sensitivity
– Poor esthetics

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Localized Gingival Recession
* Etiology-Predisposing factors
(6)

– Inadequate attached gingiva: a dimension not a
measurement (width and thickness)
– Malposed teeth
– TB habit
– Chronic inflammation
– Iatrogenic
– Factitious

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Localized Gingival Recession
* Etiology-Predisposing Factors
(5)

– Frenulum attachment
– Eruption pattern
– Smokeless tobacco
– Substance abuse (cocaine)
– Orthodontics (?)

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Localized Gingival Recession
* Treatment Objectives:
(2)

–Root coverage
–Increase the width and thickness of
keratinized tissue

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Localized Gingival Recession
* Indications:
–Root coverage:
(2)
–Width of keratinized tissue
(2)

Esthetic concern
Dentinal sensitivity
Control of plaque/inflammation
Prevent further recession

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Gingival Recession
* Patients over the age of 30 and with
recession :
– 40’s –% have an area of 3 mm of
recession
– 50’s –%
– 60’s –%
– 70’s –%
– 80’s –%

18
30
40
46
60

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Gingival Recession
* Patients examined and placed in age groups and
followed for progression of recession for 12
years. No comment on oral hygiene level.
* 3 mm of recession sites (2 mm of recession and
one mm of probing depth) had –% of sites
increase in recession.
* 4 mm of recession sites had –% of sites
increase in recession.

67
98

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Miller’s Classification of Recession
* Class I
(3)

–Marginal recession not extending to
the mucogingival junction
–No loss of interdental bone or soft
tissue
–100% root coverage possible

Miller’s Classification of Recession
* Class II
(3)

–Marginal recession extends to or
beyond the mucogingival junction
–No loss of interdental bone or soft
tissue
–100% root coverage possible

Miller’s Classification of Recession
* Class III
(3)

– Marginal tissue extends to or beyond the
mucogingival junction
– Loss of interdental bone and/or soft tissue
is apical to the CEJ, but coronal to most
apical extent of recession
– Partial but not total root coverage is
possible (50-70%)

Miller’s Classification of Recession
* Class IV
(3)

–Marginal tissue extends to or beyond
the mucogingival junction
–Loss of interdental tissue extends to
the apical extent of recession
–Root coverage cannot be anticipated

2017 World Workshop
Change from ‘Biotype’ to ‘Phenotype’
* Biotype:
* Phenotype:

(Genetics) group of organs having same specific
genotype
Appearance of an organ based on multifactorial
combination of genetic traits and environmental factors (its’
expression includes the biotype)

Phenotype may be

modified (environmental factors and
clinical intervention, think soft tissue grafting)

Periodontal Phenotype * Determined by (4)

– Gingival phenotype (gingival thickness, keratinized tissue width) – Bone morphotype (thickness of buccal bone plate) – Thin Phenotype increases risk for gingival recession – Gingival thickness

– Gingival thickness * <-- mm=thin (see probe through tissue) * >--mm=thick (cannot see probe) SRM2023

1 1

Miller Classification shortfalls * Clinically may be difficult to identify location of apical extent of recession as it relates to the mucogingival junction (MGJ) so hard to determine difference between

Class I (recession does not extend to MGJ) or Class II (recession extends to or beyond MGJ) * Does not identify how much soft or hard tissue loss is needed to determine if Class III or Class IV

Gingival Recession Classification evaluates attachment loss at

buccal and interproximal sites

Recession Type (RT) 1

Recession with no loss of interproximal attachment. Interproximal CEJ not detectable at both mesial and distal aspects RT I: Facial or lingual recession with no interproximal attachment loss

Recession Type (RT) 2

Recession associated with loss of interproximal attachment. However, interproximal attachment loss (measured from Interproximal CEJ to the depth of the interproximal sulcus/pocket) is less than or equal to depth of buccal attachment loss (measured from buccal CEJ to apical extent of buccal sulcus/pocket) RT II: Interproximal attachment loss is less than or equal to the buccal attachment loss (recession)

Recession Type (RT) 3

Recession associated with loss of interproximal attachment. However, interproximal attachment loss (measured from Interproximal CEJ to the depth of the interproximal sulcus/pocket) is higher (greater) than the buccal attachment loss (measured from buccal CEJ to apical extent of buccal sulcus/pocket) RT III: Interproximal attachment loss is greater than the buccal attachment loss

Miller Class I:

Minimal recession, does not extend to MGJ. No interproximal attachment loss

Miller Class II:

Marginal recession extends to or beyond MGJ. No proximal attachment loss.

Miller Class III:

Marginal recession extends to or beyond MGJ. Presence of interproximal attachment loss.

Miller Class IV:

Marginal recession extends to or beyond MGJ. Severe interproximal attachment loss.

Autogenous Gingival Graft * Techniques (4)

– Free Gingival Graft – Connective Tissue Graft – Semi-lunar Coronally Positioned Flap – Laterally Positioned Flap

– Free Gingival Graft * Miller’s Free Gingival Graft with use of --- * Holbrook’s Free Gingival Graft technique with---

citric acid “stretching” suture design

Autogenous Gingival Graft * Advantages (2)

– Root coverage on single or multiple teeth? – Abundant donor tissue available

Autogenous Gingival Graft * Disadvantages (3)

– Color** – Type of attachment? – Second surgical site

“Free” Gingival Graft * Graft Thickness (2)

–Primary contraction –Secondary contraction

“Free” Gingival Graft * Variation in Technique

– Placement on bone results in less mobility, less shrinkage, better hemostasis, retarded healing

“Free” Gingival Graft * Clinical Technique: Recipient Site (5)

–Anesthesia –Incision (length and angle) –Connective tissue bed preparation –Fenestration (Optional) –Hemostasis

“Free” Gingival Graft * Clinical Technique: Donor Site (2)

–Measure required graft size and mark if needed –Remove graft from palate or other area of attached tissue with scalpel or graft knife

“Free” Gingival Graft * Clinical Technique: Immobilization (3)

– Place graft in saline-soaked sponge – Place first suture in graft (out of the mouth). – Place graft onto recipient site and suture to immobilize the graft. (Suture at coronal aspect.)

“Free” Gingival Graft * Graft Thickness (2) * Variation in Technique (1)

–Primary contraction –Secondary contraction – Placement on bone results in less mobility, less shrinkage, better hemostasis, but slower healing time

“Free” Gingival Graft * Wound Healing (5)

– Plasmatic circulation (2-4 days) – Revascularization (2-8 days) – Organic Union (4-10 days) – Epithelialization (10-14 days) – Keratinization (21-180 days)