Perio Plastics I Flashcards
What ways can you distinguish gingiva from alveolar mucosa?
Visual assessment
Schiller’s iodine (detects glycogen in oral mucosa)
Roll test
How is the location of the MGJ determined
Genetically pre-determined
What happens with KG as we age? Citation
Increases due to continuous eruption of the teeth (Ainamo & Ainamo 1978)
Facial Attached Gingiva measurements/locations of widest/narrowest - citation
Bowers 1963
Ranges from 1-9mm
Widest: Maxillary Lateral Incisor
Narrowest: Mandibular 1st premolar
Lingual KG
Widest: 2PM, 1M
Narrowest: Anteriors
Voigt et al. 1978
Gingival thickness
Claffey & Shanley 1986
Thick: >2mm
Thin: <1.5mm
How thick is thin GT on average? Citation
0.8mm
Zweers et al. 2014
What makes up periodontal biotype?
Purposed by Zweers et al. 2014
Gingival Thickness
Keratinized Tissue Width
Bone morphotype
What types of periodontal biotypes were proposed?
Thin scalloped
Thick Flat
Thick Scalloped
Describe a thin scalloped phenotype
Prevalnce?
Zweers 2014
Slender triangular crowns
Thin delicate tissue with narrow KT
Thin alveolar bone
42.3% (Female > Male)
Describe a Thick Scalloped phenotype
Slender teeth
Clear thick fibrotic gingiva with narrow KT
Pronounced gingival scalloping
51.9% (Thick)
Describe thick flat phenotype
Square shaped crowns with pronounced cervical convexity
Thick fibrotic gingiva with broad KT
Thick alveolar bone
Name studies that say we need 2mm of KG
Lang and Loe 1972
Stetler and Bissada 1987 (subG Restorations)
Name studies that say we do NOT need 2mm of KG
Miyasato et al. 1977
Wennstrom & Lindhe 1983
Kennedy et al. 1985
Cortellini & Bissada 2018
What did they do in Miyasato et al. 1977? Results?
16 dental students - No OH for 25days
No difference in plaque induced inflammation in <1mm KG and >2mm KG groups
What did they do in Wennstrom and Lindhe 1983? Results?
Beagle dogs - excised KG then FGG in 50% of sites
Plaque control
NO clinical or histological inflammation in either group
What was the Stetler and Bissada 1987 Study?
Higher gingival scores in teeth with SubG restorations and narrow KG (<2mm)
NSSD when restorations were SupraG
What is the current view on KG around teeth?
In the presence of adequate OH, minimum KT is not needed to prevent CALoss
In the presence of inadequate OH, KG (2mm KG, 1mm AG) is crucial for maintenance of gingival health.
Kennedy et al. 1985
Cortellini & Bissada 2018
Name 1 study that says 2mm KG is needed around implants. Describe it
Thoma et al. 2018
Systematic Review
Autogenous grafts result in more favorable peri-implant health
Increased KTW improves BOP and marginal bone levels
Increase MT reduces likelihood of MBL
Name 1 study that says we do NOT need KG around implants. Describe it
Wennstrom & Derks 2012
Systematic Review
With goodOH, peri-implant soft tissue health can be maintained in absence of adequate amount of KG`
Name a RECENT study on KG around implants. What did it find?
Ravida et al. 2022
Systematic review, Meta analysis, and Trial Sequential Analysis
NSSD and Low power evidence for KMW impact on PD, recession, MBL
SSD mean Plaque Index for implants with 2mm+ KG
Strength of evidence of KMW as a risk factor for Pi remains low - need more control studies with larger samples
What is the INCIDENCE of recessions? Citation
O’Leary 1967
27.7% in at least 1 segment
What is the PREVALENCE of GR? Citation
Varies by size of recession
Albander & Rams 2002 (1999 NHANES Data)
_>_1mm: ~60%
_>_3mm: 23%
Rios et al. 2014 (Brazil)
_>_1mm: ~70%
_>_3mm 28%
_>_5mm: 23%
Who classified Mucogingival Deformities in the current AAP/EFP Classification?
What publication provided evidence to support it?
Jepsen et al. 2018
Cortellini & Bissada 2018
What is the difference between Periodontal Phenotype and Periodontal Biotype?
Biotype is genetically predetermined
Phenotype is determined by genetics & environmental factors
What is included in periodontal phenotype?
Gingival Phenotype(KTW, MT)
Bone Morphotype (buccal bone thickness)
What is the underlying etiology of all gingival recession?
Citation
Localized inflammatory process causing CT breakdown and Epi proliferation in its place
Baker & Seymour 1976
What etiological factors are there for recession?
According to Zucchelli
- *Traumatically induced** (Brushing, Flossing, Piercings, Prosthodontics (restorative margin), Occlusion (impinging bite), Orthodontics
- *Bacteria induced** (Plaque)
- *Virus induced** (Herpes Simplex)
- *Unknown** (Children/Teens)
- *Mixed** (Trauma/Bacteria)
What are Predisposing and Precipitating factors?
Citation
Hall 1977
Predisposing factorsL pre-determined/non-modifiable (periodontal Biotype)
Precipitating: Environmentally acquired/modifiable (trauma, plaque buildup, restorations)
What are examples of Predisposing factors?
Thin Periodontal Biotype Root prominence (dehisence) Shallow Vestibule Frenula insertion in gingival margin
How does Frenum impact recession?
Impedes patient’s oral hygiene
Breaks marginal seal favoring plaque accumulation
What are examples of Precipitating factors?
Traumatic factors (improper brushing, piercings)
Iatrogeneic factors (Ortho wires/brackets, SubG Restos)
Pathologic factors (periodontal disease/other bacteria/viruses)
Why is there increased CALoss with age? Citation
Billings et al. 2018
More recession with age - NOT deepening pocket
Is there an association between TFO and Recession?
No - Fan & Caton 2018
Bernimoulin 1977
What are the different classifications of Recessions?
Sullivan & Atkins 1968
Miller 1985
Cairo et al. 2011
What classifications are there for local factors effecting recession coverage?
Pini-Prato et al. 2010 (Identifiable CEJ: A or B, + or -)
Rasperini et al. 2018 (NCCL)
Sullivan & Atkins (year?)
How much coverage can be expected for each?
1968
3mm cutoff for deep/shallow and wide/narrow
Deep/Wide
Shallow/Wide
Deep/Narrow
Shallow/Narrow
- *Wide = 1-2mm coverage can be expected**
- *Narrow = 100% coverage (deep) or maintain (shallow)**
Miller 1985
Cairo et al. 2011
RT1: GR - no interproximal CAL (Miller 1-2)
RT2: GR with interproximal CAL < facial CAL (Miller 3)
RT3: GR with interproximal CAL > facial CAL
Pini-Prato 2010
A: CEJ detectable
B: CEJ non-detectable
+: Step
-: No step
Prevalence of different Pini-Prato classifications
A+: 45%
A-: 15%
B+: 25%
B-: 25%
What methods are there for measuring gingival thickness?
Transgingival probing
Ultrasonic measurement
Probe visibility
How accurate is transgingival probing and how do you do it?
accurate within 0.5mm (Studer et al. 1997)
Anesthetize
Pierce w/ perio probe
Use endo stopper
Who used ultrasonic measurement? Pros/cons
Eger et al. 1996
Highly reproducable
Intra-examiner error more pronounced in 2nd and 3rd molar region
What can be done to use probe visibility for gingival thickness?
Kan et al. 2010
Thin (_<_1mm) - Probe visible
Thick (>1mm) - Probe not visible
Rasperini et al. 2015
Color coded probe
Thin, Medium, Thick, Very thick
White < Green < Blue < None
What are the indications for perio-plastic surgery?
Esthetics
Hypersensitivity
Root expsure/Abrasion/Caries
Inconsistent gingival margin
What are the aims of Soft Tissue Autmentation?
Increased MT
Increase KMW
Root coverage
Deepen vestibule
What important studies have been done on Gingival Thickness?
Hwang & Wang 2006
Baldi et al. 1999
Tavelli et al. 2019a
Barootchi et al. 2022
Cairo et al. 2016 (RCT)
Zuhr et al. 2021
How does thick tissue help CAF? Citation
Hwang & Wang 2006
Resists: Inflammation/Trauma/Recession
Enables: Manipulation/Creeping Attachment/Predictable surgery
How thick does tissue need to be for predictable complete coverage in a CAF?
0.8mm (Baldi et al. 1999)
How can gingival margin/thickness be effected by ortho movement? Citation
Wennstrom 1996
Facial movement results in thinning and apical migration
Lingual movement results in thickening and coronal movement
What factors predict gingival margin stability after root coverage with ADM? Citation
Tavelli et al. 2019
12-yr follow up of RCT
GT of 1.2mm at 6mo predicted stability after multiple recession coverage w/ ADM
What factors predict gingival margin stability after root coverage with CTG? Citation
Barootchi et al 2022
When GT was 1.46mm or more at 6mo, REC change was <0.5mm at 10yrs
Aguido et al. 2016
18-35yr follow up study
84% of treated recessions exhibited recession reduction
48% of untreated recessions exhibited an increase
Who proposed vestibular extension? Why?
Nabers 1966
Shallow vestibule promotes food impaction
Oral hygiene more challenging
Who proposed FGGs? Why?
Nabers 1977
High morbidity of APF
Concurrent increasing of KT
How do we evaluate outcomes of root coverage procedures?
mRC (mean root coverage)
cRC (complete root coverage)
Both are percentages
What factors could have a negative impact when attempting complete root coverage according to Miller?
Inadequate Classification of gingival tissue recession
Inadequate root planing
Inadequate size of interdental papilla
Inadequate graft size/thickness
Graft dehydration
Inadequate adaptation of the graft
Inadequate adaptation of the graft to root or periosteal bet
Graft instability
Excess pressure in coaptation of sutured graft
Trauma during healing
Smoking
Miller 1987
What factors play a role in root coverage according to Cairo?
Interproximal bone height/CAL
What factors can influence root coverage according to Zucchelli?
papilla loss
tooth extrusion/rotation
Zuchelli et al. 2006
What are some long term studies/systematic reviews on root coverage?
Tavelli et al. 2019 (LT)
Chambrone & Tatakis 2015 (SR)
What is 1 systematic review comparing FGG with Soft tissue substitutes?
Bertl et al. 2017 (Stravropoulos)
Tavelli et al. 2019
CTG more stable over time
Recession defects tend to relapse over time
Chambrone et al. 2015
CAF+CTG, CAF+ADM, CAF+EMD, CAF+CMX
2015 AAP Regeneration Workshop
CTG had better mRC and cRC as well as increased KT
Bertl et al. 2017
With Stravropoulos
FGG vs ADM for KT increase
Larger, more predictable increase in KT width w/ FGG
ADM more aesthetic
