Plastic and Esthetic Surgery (Richardson) Flashcards
What are some indications for mucogingival surgery?
- Lack of keratinized, attached tissue,
- Recession causing root exposure and sensitivity, E. Esthetics
- Failing gingival restorations
- Thin gingiva with planned restorative or ortho,
- Frenum pulls causing recession or eversion
At what time during ortho treatment could mucogingival surgery be performed?
Prior to, during, or after
What are 5 contraindications for mucogingival surgery?
- Undiagnosed ecology
- Uncontrolled periodontal disease in site
- Severe malposed teeth
- Noncompliant patient
- Smoker
What are 8 possible etiologies for gingival recession?
- Position of tooth during eruption
- Deep restorative margin
- Orthodontic tooth movement
- Tooth brush abrasion / erosion
- Occlusion (clenching, grinding, fremitus)
- Genetic predisposition
- Trauma
- Strange habits
Lang and Loe suggest how much keratinized gingiva is adequate to maintain gingival health?
2.0mm keratinized (1.0mm of attached)
In the Dorfman and Kennedy study, what was the key between patients who received a free gingival graft and those that did not with respect to maintenance and further recession?
Those patients who had a free gingival graft but were poorly maintained showed no recession whereas those patients who were not grafted and were poorly maintained showed progression of the recession
Did the Coatam study show that if a crowded-out tooth has not keratinized tissue, would orthodontic movement back into the arch result in a gain of keratinzied tissue?
No
Coatam demonstrated that the potential for recession of keratinized tissue covered tooth is increased or decreased?
Increased
What is the prevalence of mucogingival problems in the general population?
12-19%
Miller class in which recession does not extend to or beyond the mucogingival junction and no loss of interdental bone or soft tissue?
Miller Class I
What root coverage can be anticipated for a gingival graft over Miller Class I recession?
Full coverage is anticipated
What is the Miller class in which recession DOES extend to or beyond the mucogingival junction and no loss of interdental bone or soft tissue?
Miller Class II
What root coverage can be anticipated for a gingival graft over Miller Class II recession?
Full root coverage may be anticipated
What is the Miller class in which severe recession extends to or beyond the mucogingival junction and there is loss of interdental bone or soft tissue (tooth may be severely malposed)?
Miller Class IV
Is root coverage likely in a Miller Class IV?
No
Why do Miller Class I and Class II have a better prognosis for root coverage by the graft?
They have a vascular bed from the interdental bone to go across the defect
What are 2 primary techniques to cover mucogingival defects?
- Free gingival grafts (FGG)
2. Subepithelial Connective Tissue Graft (SECT)
What are 3 healing stages for a free gingival graft?
- Plasmatic circulation 0-2 days
- Vascularization 3 days
- Organic union 4-10 days
A study in the 1970s by Brackett and Gargulo showed that blood supply not reestablished until how many days post-op from the graft placement?
7-10 days
Jahnke in 1993 showed what percentages of root coverage with Free Gingival Graft versus Subepithelial Connective Tissue Graft?
43% FGG
80% SECT
What is the primary technique for root coverage?
SECT graft
What is the major benefit of the sub epithelial connective tissue graft?
Augments the amount of keratinized gingival in ESTHETIC manner
What percentage of root coverage from a SECT if there is less than 3mm of recession?
100%
What percentage of root coverage from SECT if 4-6mm of recession?
90%
What percentage of root coverage from SECT if 7-10mm recession?
85%
What are 3 advantages of an SECT graft?
- Effective root coverage
- Esthetic color match
- Long term stability
What are 3 advantages of Free Gingival Graft?
- Effective at establishing zone of keratinized tissue
- Does not require coverage at recipient site
- Long term stability
What are 2 disadvantages of free gingival graft?
- Not intended for root coverage
2. Less accurate color match
What graft would be indicated in age of #6 or #11 with recession and why?
SECT due to esthetic zone will match color of overlying gingiva (FGG has tied-tread appearance and will be different color)
What determines the phenotype of the overlying epithelium and how can this be used in gingival grafting?
Underlying CT. If you take the SECT from a keratinized portion of the palate, put it under mucose, allow to heal, then go back and abrade the mucosa. It will heal keratinized.
What is a major concern when harvesting an autogenous graft from the palate?
Avoiding a greater palatine artery
What direction is the first incision for the autogenous graft made?
Perpendicular to long axis of the tooth
What is the average distance from the CEJ of the maxillary tooth to the bend in an average palate where the Greater palatine artery and nerve lie behind? High palate? Shallow?
Average 12mm
High 17mm
Shallow 7mm
When taking an autogenous graft, how much should you take?
Take as much as you can get, patient will be uncomfortable with small or large donor sites
Does graft thickness have an affect on healing?
Yes
Do thicker grafts undergo more primary shrinkage at harvesting or more secondary contraction during healing?
More primary shrinkage at harvest and less secondary contraction during healing
Which graft will required more time for revascularization: thick or thin?
Thicker
What is the ideal graft thickness?
0.75 to 1.25mm
What are 3 indications for soft tissue augmentation prior to ortho?
- Facial movement planned and les than 1 mm apicocoronal height of keratinized tissue
- Thin tissue
- Poor oral hygiene
How can one tell that tissue is thin?
Root or probe is visible
If a tooth with 0.0 mm of keratinized gingiva is orthodontically moved, how much keratinized gingiva will it have once moved?
0.0 mm
What percent of the time will a tooth that has 0.0mm keratinized gingiva be associated with a cleft?
27%
Is there enough risk of recession during tooth movement in a patient without an adequate amount of gingiva to justify pre-orthodontic augmentation of the gingiva?
Yes
What increases the risk of susceptibility to recession when considering ortho?
Minimum buccal-lingual
What is most likely present in an adolescent with a thin periodontium?
Fenestrationg and/or dehiscences
When considering ortho and recession, the recession of the marginal tissue is dependent on the existence or creation of what?
Dehiscences of the alveolar bone
What can be expected if a patient with minimal or no keratinized tissue undergoes ortho therapy without grafting and recession develops?
Litigation
What is the goal of every dentist?
Maintenance of dentition in a state of optimal health, comfort and function with reasonable esthetics
What must be discussed with recession, can be demonstrated to be progressive, and creates a concern for the dentist or the patient?
The need to create a broader band of attached gingiva
What does the decision to perform surgery to create a broader band of attached gingiva demand?
Clinical judgement (that amount of gingiva which is sufficient to prevent recession in the opinion of the individual clinician)
What are 6 factors that influence clinical judgment?
- Age / health of patient
- Volume of periodontium
- Prominence of root in the alveolus
- Tooth brushing habits
- Frenum attachments
- Period ob observation / evaluation of the area
Is the presence or absence of keratinized gingiva a factor in the successful osseointegration of implant fixtures?
No
What was strongly correlated with optimal sot and hard tissue health in the posterior mandible when considering implants?
Presence of keratinized gingiva
What are 2 culprits in a substantial number of failures in long-term observations of dental implants?
- Poor oral hygiene
2. Inadequate keratinized gingiva
What has been found to be true with regard to keratinized mucosa and its importance in avoiding complications, obtaining esthetic results in prosthetic rehabilitation of the anterior dentition for implant supported single or multiple unit prostheses with a submucosal implant prosthetic junction?
The implant should be surrounded by non mobile keratinized mucosa
What does having keratinized tissue in the area of the implant aide?
Seals and protects CT and bone around the implant
What are 3 things keratinized tissue around the collar of the implant does?
- Prevents trauma from plaque control procedures
- Facilitate maintenance by hygienist
- Facilitates impression-making
How much keratinized tissue is required if a dentist plans a restorative procedure that enters the gingival crevice?
- Approximately 5.0mm keratinized tissue
- 2.0mm free gingiva
- 3.0mm attached gingiva
What makes attached gingiva a better deterrent to the infiltration of inflammation elements?
Closely packed collagen fibers in attached gingiva
In sites with a wide zone of keratinized gingiva, it was found that the inflammatory infiltrate was confined to what area?
The tooth side of the free gingiva
What may occur if a sub gingival margin is placed in an area lacking narrow or no keratinized gingiva and sub gingival plaque accumulates?
Recession
Studies showed what dimension of keratinized gingiva has increased gingival inflammation in the presence of a sub gingival restoration?
Less than 2.0mm
What are alternative materials for gingival grafts instead of auto grafting from a palatal donor site?
Alloderm, mucograft, allocell, emdogain, GEM21, placenta, synthetics
Cells that are important in the formation of peridontium when doing GTR?
Osteoblasts, cementoblasts, PDL fibroblasts. A membrane keeps out fast-growing epithelial cells
What is an autogenous graft from the palate that includes epithelium and the underlying CT whose goal is to increase the zone of keratinized gingiva?
Free gingival graft
Is a free gingival graft indicated when root coverage is desired?
No
What is an autogenous graft from the palate that does not include epithelium, but only the underlying CT show goals is to increase the gingival thickness, obtain root coverage, and potentially gain keratinized gingiva?
CT graft
What is the Miller Class in which recession extends to or beyond the mucogingival junction and there is loss of bone or interdental tissue (tooth may be severely malposed)?
Miller Class III
Is full root coverage anticipated for a gingival graft in a miller class III?
Full root coverage NOT expected
