perio plastic surgery Flashcards
def of mucogingival conditions
deviations from norm anatomic relation btwn gingival margin and MGJ
common mucogingival conditions
- recession
- loss of keratinized tissue
- probing depths beyond MGJ
anatomy that can imapct how mucogingival defects are treated
- tooth position
- frenum position
- vestibular depth
can ridge anatomy impact mucogingival conditions?
yes
classes of mucogingival deformities
- localized tooth factors that mod or predispose to plaque induced dx
- mucoging conditions around teeth
- mucoging condtions of edentulous ridges
How much KT is enough?
– Bowers 63: normal varies from?
– Lang and Loe 72: need ? keratinized, ?
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
for exam purposes:
– Bowers 63: normal varies from 1-9mm
– Lang and Loe 72: need 2 mm keratinized, 1mm attached
– Maynard and Wilson 79: 5mm keratinized needed for restorative with 3 mm attached
– Dorfman and Kennedy 80: less than 1 mm is adequate if inflammation is controlled
– Freedman et al 99: 18 year study, less than 1 mm is adequate if inflammation is controlled
for exam: 2mm or greater
esthetic enhancement of MG sx
when is this applicable:
gingiva?
alveolar ridge?
Providing a more esthetically acceptable gingival form and contour
– Localized gingival recession (today’s topic)
– Localized alveolar ridge deficiency
– Excessive gingival display
– Gingival enlargement or asymmetry
Recession definition
- Apical shift of the gingival margin, associated with attachment loss
etiologies of recession
– Toothbrush abrasion
– Frenal attachment
– Intrasulcular restorative margin placement*
– Orthodontics-dependent upon direction and bucco- lingual soft
tissue thickness
Potential consequences of gingival recession
Exposed root surface making it potentially more susceptible
to
– Root caries
– Non-carious cervical lesions (NCCL’s)
– Dentinal sensitivity
– Poor esthetics
what is always asked with recession
sensitivity/esthetic issues?
predisposing factors to localized recession:
– Inadequate?
– Malposed?
– habit?
– inflam?
– Iatrogenic?
– Factitious?
– Inadequate attached gingiva: a dimension not a measurement (width and thickness)
– Malposed teeth
– TB habit
– Chronic inflammation
– Iatrogenic
– Factitious
inadequate attatched gingiva
**localized **gingival recession etiology-predisposing factors:
- Frenulum?
– Eruption?
– tobacco?
– Substances?
– Ortho?
- Frenulum attachment
– Eruption pattern
– Smokeless tobacco
– Substance abuse (cocaine)
– Orthodontics (?)
frenae attatchment
Localized Gingival Recession
* Treatment Objectives:
* root/KT
–Root coverage
–Increase the width and thickness of
keratinized tissue
indications for root coverage
- Esthetic concern
- Dentinal sensitivity
indications for increased width of KT
- Control of?
- Prevent?
- Control of plaque/inflammation
- Prevent further recession
by decade
Patients over the age of 40 and with recession :
gingival recession with 3mm vs 4mm 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 67% of sites increase in recession.
- 4 mm of recession sites had 98% of sites increase in recession
millers class 1 recession
–Marginal recession?
–No loss of?
–% root coverage possible
–Marginal recession not extending to
the mucogingival junction
–No loss of interdental bone or soft
tissue
–100% root coverage possible
miller class 2
–Marginal recession extends?
-loss of interdental bone or soft
tissue?
–% root coverage possible
–Marginal recession extends to or
beyond the mucogingival junction
–No loss of interdental bone or soft
tissue
–100% root coverage possible
miller class 3
– Marginal tissue extends?
– Loss of interdental bone and/or soft tissue?
– root coverage?
– 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 class 4
–Marginal tissue extends?
–Loss of interdental tissue extends?
–Root coverage?
–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
biotype to phenotype
- Biotype:(Genetics) group of organs having same specific genotype
- Phenotype: 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
– Gingival phenotype (gingival thickness, keratinized tissue width)
– Bone morphotype (thickness of buccal bone plate)
thin pheno implication
– Thin Phenotype increases risk for gingival recession
gingivo thicknesses
– Gingival thickness
* <1mm=thin (see probe through tissue)
* >1mm=thick (cannot see probe)
Miller Classification shortfalls
* Clinically may be difficult to identify?
* Does not identify how much soft or hard tissue loss is needed to?
- 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
recession type classes
RT 1 to 3, also called cairo
RT1
Facial or lingual recession with no interproximal attachment loss
simmilar to miller 1 and 2
RT 2
Interproximal attachment loss is less
than or equal to the buccal attachment loss (recession)
similar to miller 3
RT3
Interproximal attachment loss is greater than the buccal attachment loss
miller 4
push back procedure
not used very often due to unesthetic result.
refelct and move tissue apically resulting in granulation tissue with a zero probing depth
Autogenous Gingival Graft
* Advantages
– Root coverage on single or multiple teeth?
– Abundant donor tissue available
Autogenous Gingival Graft * Disadvantages
– Color
– Type of attachment?
– Second surgical site
“Free” Gingival Graft
* Graft Thickness
–Primary contraction
–Secondary contraction
“Free” Gingival Graft
variation in technique: placement on bone results
– Placement on bone results in less mobility, less shrinkage, better hemostasis, retarded healing
“Free” Gingival Graft
* Clinical Technique: Recipient Site
–Anesthesia
–Incision (length and angle)
–Connective tissue bed preparation
–Fenestration (Optional)
–Hemostasis
“Free” Gingival Graft
* Clinical Technique: Donor Site
–Measure?
–Remove graft from? with?
–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
– Place graft in?
– Place first suture in?
– Place graft onto? and?
– 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
–Primary contraction
–Secondary contraction
“Free” Gingival Graft Variation in Technique
– Placement of graft on bone results in?
– Placement on bone results in less mobility, less shrinkage, better hemostasis, but slower healing time
“Free” Gingival Graft
* Wound Healing
– Plasmatic circulation?
– Revascularization?
– Organic Union?
– Epithelialization?
– Keratinization?
– Plasmatic circulation (2-4 days)
– Revascularization (2-8 days)
– Organic Union (4-10 days)
– Epithelialization (10-14 days)
– Keratinization (21-180 days)
order of healing in gingival free graft
– Plasmatic circulation (2-4 days)
– Revascularization (2-8 days)
– Organic Union (4-10 days)
– Epithelialization (10-14 days)
– Keratinization (21-180 days)
how does free gingival graft recieve blood supply
periosteum and wound
Free gingival graft appearence post op
can look like it is failing but give it time
how do you calculate CAL?
PD-KT
