Perio Flashcards
Factors influencing gingival recession
Periodontal phenotype Presence of periodontal disease and its treatment Muscle attachments Trauma Tooth position Iatrogenic factors
Gingival phenotype
Bone morphology
Gingival phenotype = gingival thickness + keratinised tissue width < can be measured by inserting probe
Bone morphology = thickness of bone plate
Types of trauma:
Mechanical - TB (evidence inconc.), choice of TB
Physical - piercings, poor dentures, habitual behaviors, foods
Chemical - drugs, irritants, tobacco
Tooth positions:
Bucco-lingual position and orientation of tooth can influence thickness of overlying gingival tissues
Mandibular incisors most susceptible to post-ortho recession
Correlation between labial bone dehiscences and recession defects
Deep overbite - trauma to palatal tissues and recession - Akerley classification
Iatrogenic factors
Overheated/USS tips Encroachment on supra-crestal width Poorly contoured restorations - plaque retentive Surgical procedures Irritants Rubber dam clamps
Sequalae of gingival recession
Dentine hypersensitivity
Non carious cervical lesions/root caries - pulp necrosis
Impaired aesthetics - open embrasures, exposed crown margins
Classification of gingival recession
Millers classification - class I - IV - old New classification - WWP (2017) based on Cairo et al., 2011 RT1 (full c), RT2 (partial c), RT3 (no c)
Conservative management gingival recession:
Reassurance
Baseline records for objective monitoring - clinical photos, dated study models, clinical measurements
Recognition and management of contributing factors - plaque retentive, tooth position, ortho, remove traumatic features, mx of habits
Sensitivity - F- varnish, dentine bonding agents, cervical lesions restored with GIC/composite
Non-surgical management gingival recession:
Pink composite
Pink ceramic
Gingival veneers
Surgical management gingival recession:
- Pedicle flap procedures - coronally advanced flap, rotational flaps
- Free soft tissue grafts - free gingival graft, connective tissue graft, processed tissue graft
- Regeneration procedures - guided tissue regeneration, enamel matrix derivative, leukocyte and platelet rich fibrin
Indications for gingival recession surgery
Progressive breakdown Hypersensitivity Aesthetics Unfavourable contour of gingival margin - limiting effective plaque control ? prior to ortho if dehiscence likely
Contraindications for gingival recession surgery:
Smoking Poor OH Periodontal pocketing Uncontrolled aetiological factors e.g. self-inflicted trauma Severe defects e.g. RT3, wide defects Poor donor sites Poor access for surgery MH considerations
Pedicle flap procedures (2):
Coronally advanced flap (CAF) - coronal shift of pedicle flap onto exposed root surface. Ensure at least 3mm keratinised tissue apical to defect. + Reported as most predictable for generalised&localised defects if sufficient and good donor tissue.
+ Can be used in combo with grafts to increase expected RC.
Rotational flap - double papilla flap - 2 papillae slide from adjacent tooth and sutured over to cover exposed root surface. Requires tissue of adequate length thickness and width of KT adjacent to defect.
+ Good for localised defects, esp if narrow defect
- potential bone loss or gingival recession at donor site
Free soft tissue gingival graft procedures:
Free gingival graft (FGG): not 1^ aim of root coverage but can be by-product. Done when wanting to ^ width of band of keratinised tissue. Can be to improve local OH, deepen vestibule, prevent fraenal reattachment, pre-ortho/implants if risk of recession high/show through
Donor site - premolar region of palate, avoid palatine vessels. Prepare recipient site - split thickness flap to expose underlying CT, extend 3mm beyond defect, donor graft placed in situ on recipient bed, interrupted sutures to close. Donor ideally 2mm thick and larger than recipient site.
Subepithelial CT graft (CTG): - similar to FGG, but aim of this procedure is full root coverage. Split thickness flap w/2 lateral relieving incisions. Donor tissue harvested from palate using trap door technique - avoiding rugae. Graft placed over recipient site and split thickness flap sutured over top of graft
++ dual blood supply from sub-epithelial tissue base and overlying flap
Processed soft tissue grafts - xenogenic collagen matrices (XCM) or cellular dermal matrix allographs (ADMAs). Porcine bioresorbable product which encourages regeneration of keratinised tissue around teeth/implants w/recession defects.
- Limited evidence but
+ good for pt’s with lack of donor tissue e.g. thin gingival & periodontal phenotypes
Split thickness flap raised, XCM cut to size of defect, moistened, placed in recipient site
Can be combined wirh coronally advanced flaps
Regeneration precedures:
Guided tissue regeneration - used for mgt of alveolar bone loss or localised bony defects. Can be used for reconstruction of recession defects.
+ possibility periodontal regeneration
- studies show CTG better
Enamel matrix derivative - porcine product used in combo with CAF for periodontal regeneration of recession defects.
+ similar root coverage achieved compared to CTG, no need for donor site
- systematic review shows CTG + CAF achieves better keratinised tissue thickness than EMD + CAF
- not suitable for all recession defects
Leukocyte and platelet rich fibrin - 2nd gen platelet concentrate used in conjunction with CAF. LRPF source of autogenous growth factors - pt’s blood taken and centrifuged. PRF layer used
- limited evidence as new technique
