Perio Plastics II Flashcards
Who classified clinical management of non-proximal recession defects?
Chambrone & Avila-Ortiz 2021
What are the 3 Subtypes of the recession treatment classification based on?
Attached Gingiva and Gingival Thickness
What is Subtype A?
_>_1mm AG
_>_1mm MT
What is Subtype B?
_>_1mm AG
_<_1mm MT
What is Subtype C?
_<_1mm AG
What Tx options for Subtype A?
RT½: CAF or LPF (alternative: Bilaminar)
RT3: NOT RECOMMENDED
What Tx options for Subtype B
RT½: Bilaminar (alternative LPF)
RT3: Bilaminar may be indicated
What Tx options for Subtype C?
RT½: FGG (alternative: Tunnel/LPF)
RT3: FGG may be indicated
What happens to KG with time after CAF? Why?
It increases - repositioning of the MGJ to its genetically pre-determined position (Zucchelli)
Who first described CAF?
Bernimoulin 1975
How much advancement do you need for CAF? Why? Citation?
Pini-Prato et al. 2005 (prospective)
2mm above CEJ was associated with 100% CRC
3mm recession required 2.5mm after logistic regression
More mm of coverage can be expected when treating a larger recession
1mm apical migration of MGJ after 6mo
What rationale is there for CAF?
Root Coverage
Adequate KT apical to the root
Good OH
Maxillary anterior (more aesthetic)
Whats the minimum flap thickness for CAF alone? Citation What if its less? Citation
0.8mm (Baldi et al. 1999)
then CAF+CTG have better outcome (Cairo 2016)
What determines what kind of material you use?
Flap thickness!
Where should flap thickness be measured?
2mm below the gingival margin
How wide should the surgical papilla be and how far from the peak of the anatomical papilla? (Citation)
3mm wide
X (recession depth) +1
Zucchelli et al. 2007
(Wang says it was him)
What is the rationale behind split-full-split?
Makes use of the periosteum to cover the denuded avascular root surface
What is the Pro/Con of a triangular incision for CAF? When should you use it? Citation
Trapezoidal has more keloid formation
Triangular is more technique sensitive
When there is not 3mm interproximally for the surgical papilla width
Zucchelli et al. 2016
What article compared CAF vs CAF+CTG?
Cairo et al. 2016
How does CAF compare to CAF+CTG? Citation
32pts - RCT - 1yr FU
In GT <0.8mm CAF+CTG >> CAF alone
CAF higher esthetic score in thick gingiva
Cairo et al. 2016
What was the first form of tunneling? Describe it Citation
the Semilunar incision
Semilunar incision parallel to gingival margin - split thickness apically
no sutures
Tarnow 1986
Who described the lateral sliding flap/modification?
Grupe 1956
Grupe 1966
What are indications/drawbacks to the Lateral Sliding Flap? How does the modification help with the drawback?
Ideal for isolated gingival recessions
Better esthetic vs FGG
Recession at the donor site!
Modification allows 3mm apical to donor margin to avoid recession
Who first described the double papilla flap?
Cohen & Ross 1968
Who developed the Envelope flap?
Raetzke 1985
What is the Envelope flap?
Partial thickness around the defect
Graft placed like a tunnel with middle exposed
Middle retains epi
What are clinical benefits of FGG vs APF?
FGG increases both KTW and Thickness vs APF
How does placing FGG on Bone vs Periosteum effect the outcome? CitationS
Dordick et al. 1976
FGG on bone: no mobility - less swelling
BUT 2 week “lag” in healing vs periosteum
Less shrinkage on bone (James et al. 1978)
What is a big advantage of using autogenous tissue?
Creeping Attachment
What cells do Autogenous Grafts contain? What does this provide?
Keratinocytes and Fibroblasts
Creeping Attachment
What flaps maintain their blood supply specifically?
CAF, Double Papilla, Lateral Sliding, Envelope, Semilunar
What does graft survival depend on for free grafts? why? Citation
Close adaptation to the recipient bed - facilitates revascularization (Yu et al. 2018)
How does esposing some of a CTG effect the outcome? Citation
Exposed site will gain KT
Covered cites will provide more recession reduction
Dodge et al. 2018
What phases of contraction are there for FGG? What is responsible for each? Citation
Primary and Secondary
Primary: due to amount of elastic fibers in graft
Secondary: cicatrization between graft and recipient bed
Sullivan & Atkins 1968
How does graft thickness effect FGG shrinkage?
Thicker grafts have less secondary contraction
How thick should an FGG be to avoid pain?? citation
_<_2mm (Burkhardt et al. 2015)
Residual tissue thickness of _>_2mm = less post op pain (Zucchelli et al. 2010)
How thick do classic studies say an FGG should be? How thick do we do?
0.75-1.25mm (Soehren et al. 1973)
1-1.5mm
Rationale for FGG
increase KT, AG, Vestibular depth, and increase tissue thickness
how do FGG perform long term?
4.2mm increase in KT after 1yr
0.7mm decrease after 10-25yrs
Aguido et al. 2008
Who developed the 2 step approach?
Bernimoulin et al. 1975
When would you consider a 2 step approach instead of a CTG?
Shallow vestibule
non-esthetic zone
NO KT
How much creeping attachment can we expect with CTG?
0.89mm but depends on:
Width of recession (narrow>wide - 3mm)
Position of graft (over denuted surface)
Bone resorption
Position of tooth
Hygene
From 3mo - 1yr
Matter & Cimasoni 1976
What is the benefit of a De-Epithelialized CTG vs sCTG?
less fatty/glandular tissue
How does sCTG compare to De-epiCTG? Citation
NSSD in post-op pain or root coverage outcomes (Zucchelli et al. 2010)
More GT with De-epiCTG !!! (Less graft shrinkage)
How can you help attain hemostasis from donor site?
Collatape, Gelfoam, ozone therapy, Oxidized cellulose
Who developed tunneling?
Zabalegui et al. 1999
How does Tunneling compare to CAF? Citation
Tavelli et al. 2018
Systematic review/meta analysis
Similar outcomes
CAF > TUN when same material compared
Who developed the VISTA approach? What is it?
Zadeh 2011
Tunnel with a VR in the mucosa for better access
used COMPOSITE to maintain sutures coronally
rhPDGF+B-TCP
When treating multiple recessions, where should you suture first?
Periphery stabilized, the suture toward the center of the flap
How much coronal advancement should we gt for CRC? citation
2mm above CEJ (Pini Prato et al. 2005)
What type of sutures are used for fixing pedicle flaps?
Interrupted and Suspensory (Sling/Double Sling)
What kind of healing takes place histologically with diffferent procedures? citation
Zucchelli & Mounssif 2015
for CAF, CAF+CTG, and FGG
New connective tissue
Long junctional epithelium
Who researched healing of Lateral Pedicle flap?
Wilderman & Wentz 1965
Healing of Lateral Pedicle Flap
Adaptation (0-4)
Proliferation (4-21)
Attachment (27-28)
Maturation
Wilderman & Wentz
Who researched healing of CTG?
Guiha et al. 2001
Healing of CTG
Day 7: Blood vessels from both sides of graft
Day 14: Complete vascularization of graft
Day 28: JE formed
Day 28-60: Normal vascularization/oral epithelium
How much CTG can be exposed? itation
30%
Guiha et al. 2001
Where do vessels come from to supply CT Graft?
Periodontal plexus
Supraperiosteal Plexus
Flap (subepithelial/crevicular plexuses)
Who studied the healing of FGG?
Oliver 1968
Healing of FGG
0-3: Initial (Plasmatic Circulation)
4-11: Revascularization
11-42: Maturation
How doe primary contraction impact the graft healing?
Shrinkage due to the amount of elastic fibers which causes vessel collapse and delays graft vascularization
What is the Cairo esthetic score?
1: Gingival Margin level
2: Marginal contour
3: Tissue Texture
4: MGJ Alignment
5: Gingival color
What options are there for papilla reconstruction?
Envelope
Vertical tissue growth with Tuberosity
Classification of gingival recession around implants (Classes)
Zucchelli 2019
CIass I: No recession - only color change - good implant position
Class II: Some mid-facial recession - no papilla recession (facial of crown is slightly palatal)
Class III: Papilla loss - good implant position
Class IV: Papilla loss - poor implant position
Classification of gingival recession around implants (Subclasses)
Tip of papilla to Gingival Margin
Subclass A: Both papilla _\>_3mm Subclass B: at least 1 papilla is 1-3mm Subclass C: at least 1 papilla is \<1mm
When can you expect creeping attachment?
In Narrow Deep defects
