Perio (Recession, Surgery, Perio Phenotype) Flashcards
Which team first introduced thick vs thin periodontal biotype?
Maynard & Wilson (1979)
Thick - more resistant to recession, better response to surgical manipulation
Thin - More prone to recession
Miller Classification (4)?
Which two have predictable root coverage?
- Recession does not extend to MGJ w/ no perio bone loss interdental
- Recession extends to MGJ or beyond w/ no perio bone loss
- Recession extends to MGJ or beyond with some period bone loss or malpositioning of teeth
- Recession extends to or beyond MGJ with severe bone loss and/or severe malpositioning of teeth
B. Class I/II have predictable; Class III has partial
Cairo Recession Classification (3) and what is their equivalent in Miller?
In which category is full root coverage not possible?
RT1: Recession w/o interdental CAL (encompass Miller I/II)
RT2: Recession w/ inter proximal CAL, but buccal CAL > Interdental CAL (Miller III)
RT3: Interdental CAL > buccal CAL (Full root coverage not achievable) (Miller IV)
Kan - Gingival thickness - What were the measurements for thick and for thin?
Thin: < 1.1 mm
Thick: > 1.1 mm
Glickman Classification of furcations (IV)
I: Slightly noticeable
II: Definite horizontal component of a few mm
III: Can go through
IV: Can go through and you can visualize due to soft tissue recession
Methods to assess Periodontal biotype? (5)
- Visual (not reliable)
- Probe through tissue
- Ultrasound
- Probe facial sulcus (Kan)
- CBCT
What are the three periodontal biotypes?
Out of the following, which measurements had positive associations based on the Zweers 2014 SR: Bone morphotype, dental dimension, gingival dimension, gingival thickness, keratinized tissue, and osseous dimension
- Thin scalloped
- Thick flat
- Thick scalloped
Positive: Gingival thickness, keratinized tissue, and bone morphotype
Weak/moderate: Dental, gingival, and osseous dimension
Based on the 2019 AAP Best Evidence Consensus, is there any evidence that gingival type leads to more recession?
Yes, thin and narrow gingiva subjects have more gingival recession than those with thick and wide
Based on the 2019 AAP Best Evidence Consensus, is there evidence supporting converting thin to thick gingival phenotypes in sites without gingival recession or mucogingival deformity?
No, there is zero published evidence supporting conversion from thin to thick.
How much force to use when perio probing?
20-25 g
Osborn and Van der Weijden - minimize tissue trauma or penetrate beyond junctional epithelium
How did you determine your patient’s gingival biotype?
Difficult to assess since she has anterior four crowned and mandibular spacing.
Thick-flat biotypes have short papillae with large amount of attached mucosa with flatter posterior cusps.
She didn’t fall under thin scalloped as she doesn’t have highly scalloped or translucent gingiva with minimal keratinized tissue.
Not thick scalloped since they have long papillae.
Three reasons to do soft tissue grafting?
- Increase KG
- Increase tissue thickness
- Root coverage
What kind of tissue and technique did they use for the CTG?
What kind for the FGG?
CTG: Allograft (Puros), tunneling technique for #3-5.
29, 30 with CAF (3 mm beyond CEJ), harvested CTG from UR palate.
CTG #11, 12, 24, 25 - UL palate CTG with tunneling technique and CAF.
FGG: #24 and 25 - Right palate
Per Leong/Wang Soft Tissue Grafting Decision tree
- What procedures available to augment zone of KG? (4)
Apically positioned flap (APF)
Free soft tissue grafting (FST)
Laterally positioned flap (LPF)
Two-stage connective tissue graft (CT)
Per Leong/Wang Soft Tissue Grafting Decision tree
- What procedures to increase tissue thickness?
- CT graft / FGG
- Coronally advanced flap
- Bone graft
- Accellular dermal matrix graft
Per Leong/Wang Soft Tissue Grafting Decision tree
What procedures when there is no inter proximal bone loss if thin (1) or thick tissue (5)?
- Thin (< 1): CT graft (with deepithilization at 12 weeks) is the gold standard for root coverage, clinical attachment, and KT gain
- Thick (>2): Any soft tissue procedure (CT graft, CAF (0.8 to 1.2 mm thick), GTR, ADM, LPF, or combination) - Can pick any of them.
Per Leong/Wang Soft Tissue Grafting Decision tree
What is the goal with inter proximal bone loss presentation (Miller III/IV)?
What procedures are possible?
Only partial root coverage (70-75%) expected for Miller III. Root coverage unpredictable, so goal is phenotype conversion and KT Gain = functional and esthetic improvement, not full correction. Make tissue more resilient and easy for hygiene.
✅ CTG + CAF is the best option for limited root coverage.
✅ FGG is best for keratinized tissue width enhancement in non-esthetic zones.
✅ GTR techniques have limited but evolving success.
PDL role?
PDL composition?
Innervated?
- Role: Shock absorber via attach tooth via cementum to bone
- Type 1 collagen and other collagens, proteoglycans, water, blood vessels
- Yes, pain and mechanoreceptors - likely just at apical third
What are the 5 types of alveolar dental PDL?
What are the 5 types of gingival PDL?
A. Alveolar crest
B. Horizontal
C. Oblique
D. Apical
E. Interradicular (between roots)
A. Dentogingival
B. Alveolargingival
C. Circular
D. Dentoperiosteal
E. Transseptal (cementum to other teeth cementum
Role of Cementum (2)
- Attach teeth to bond via Sharpey’s fibers of PDL
- Prevent root resorption
Healing of a CTG (5)
Mnemonic: “ICERM” – Initial Clot, Connect, Epithelialize, Remodel, Maturate”
I - Initial Clot Formation (0-3 Days)
Blood clot stabilizes the graft, providing nutrients and protection.
Fibrin network forms to hold the graft in place.
C - Connect & Revascularization (3-7 Days)
Anastomosis of graft vessels to recipient site vessels.
Epithelial downgrowth begins at margins.
E - Epithelialization (1-2 Weeks)
Epithelium covers the graft, protecting underlying connective tissue.
Fibroblasts migrate into the graft to support integration.
R - Remodeling (2-4 Weeks)
Collagen remodeling begins, and vascular network stabilizes.
Graft integrates into the recipient site’s connective tissue.
M - Maturation (1-3 Months)
Tissue thickens and keratinizes.
Final esthetic and functional results achieved.
Healing of FGG (4)
Mnemonic: “PCER” – Plasmatic Diffusion, Capillary Invasion, Epithelialization, Remodeling”
P - Plasmatic Diffusion (0-3 Days)
The graft survives initially through diffusion of nutrients from the recipient bed.
A fibrin clot stabilizes the graft.
C - Capillary Invasion (2-7 Days)
New capillaries begin growing from the recipient site into the graft.
Graft appears pale initially, then becomes reddish as vascularization improves.
E - Epithelialization (1-2 Weeks)
Superficial epithelium undergoes necrosis and is replaced by new epithelial cells from adjacent tissues.
The graft surface starts to look more natural.
R - Remodeling & Maturation (1-3 Months)
The graft integrates fully, thickens, and keratinizes.
Final color and texture stabilize.
Difference from FGG and CTG (4)
FGG is fully epithelialized, while CTG is primarily subepithelial connective tissue.
FGG relies more on plasmatic diffusion early on since it lacks an initial vascular supply.
FGG takes longer to blend in esthetically due to its visible nature.
FGG ideal for keratinized tissue or frenum attachment areas.
