S2 - Aesthetic Periodontal Surgery Flashcards
What is gingival (marginal tissue) recession?
displacement of location of marginal periodontal tissue apical to the CEJ
Name some predisposing factors of recession (NOT precipitating)
- gingival biotype
- aberrant frenal attachment
- bone dehiscence
- quantity of attached gingiva
5 types of predisposing* and precipitating+ factors of recession. Specify each and give examples. Which are most/less common?
Mechanical forces
- faulty toothbrushing+
- oral piercing+
- occlusal injury+
Iatrogenic
- orthodontic movement+
- restorative dentistry+
Pathological
plaque induced inflammation (smoking+)
Ageing
Anatomy
- bone dehiscence*
- malocclusion+
- tooth position+
- gingival biotype*
- aberrant frenal attachment*
- quantity of attached gingiva*
mechanical and anatomy (often in combo) more common than pathological)
Miller’s 1985 classification of recession. (4)
Class I: marginal tissue recession that does not extend to the MGJ with no interproximal tissue loss
Class II: marginal tissue recession that extends to or beyond the MGJ with no periodontal attachment loss in interdental area
Class III: marginal tissue recession that extends to or beyond the MGJ with periodontal attachment loss in the interdental area or malpositioning of teeth
Class IV: marginal tissue recession that extends to or beyond the MGJ, with severe bone or soft-tissue loss in interdental area, to a level apical to buccal/labial soft tissue margin and/or severe malpositioning of teeth
3 indications for root coverage
- reduce root sensitivity
- improve esthetics
- manage muco-gingival defects
What is a pedicle soft tissue graft?
one end of graft still attached to donor site
What is a free soft tissue graft?
graft completely detached from donor site
What is an additive graft treatment?
graft material sourced commercially
2 categories of pedicle soft tissue grafts and 2 subcategories of each
Rotational Flaps
- laterally positioned flap
- double papilla flap
Advanced Flaps
- coronally positioned flap
- semilunar flap
2 categories of free soft tissue grafts. What do they mean?
Non-submerged grafts
- free gingival graft
Submerged grafts
- subepithelial connective tissue graft
4 types of submerged graft approaches
- Connective tissue graft + lateral pedicle flap
- CTG + double papilla
- CTG + coronally positioned flap
- tunnel approach
2 types of additive treatments
GTR
Enamel protein derivatives
Indications (2) and contraindications (3) of laterally positioned flap.
Indications:
- Millers class I and II
- adequate adjacent donor
Contraindications:
- deep inter-proximal pocket or bone loss
- significant loss of interproximal bone height*
- excessive root prominences
*will just shrink as bone dictates where soft tissue will heal
Procedure for laterally positioned flap (5)
- V-shaped incision on denuded roots to remove adjacent epithelium and CT
- Parallel incision at an oblique angle toward the recipient tooth
- Partial thickness flap extending into mucosa
- Pedicle flap positioned laterally
- Interrupted sutures and sling sutures
(Sutures removed after 10-14 days)
Advantage (1) and disadvantages (4) of pedicle flap
Advantages: good vascularity of pedicle flap
Disadvantages:
- possibility of recession at donor site
- limited by amt of adjacent tissue
- dehiscence or fenestration at donor site
- can be used in single or 2 teeth recession
What is a double papilla laterally positioned flap? What are the 2 indications?
flap using 2 adjacent papillae to cover a denuded root surface
- wide adjacent interproximal papilla
- insufficient attached gingiva for lateral pedicle graft
Key points to note about free gingival graft? (5)
- increases width of attached gingiva
- colour mismatch
- raw wound in palate
- single source of blood supply
- more useful in less visible areas
What is a sub-epithelial connective tissue graft (1)
- a wedge of palatal CT is inserted below the exisitng epithelium of recipient site
What are some possible donor sites for sub-epithelial connective tissue graft?
Key points about sub-epithelial CT graft (5)
- most consistently predictable method of root coverage
- colour match
- technique sensitive
- primary closure in palate
- dual source of blood supply - donor bed and flap on top (by combining with pedicle flap, it takes advantage of the blood supply from CT, periosteum as well as overlying flap)
Key points about tunnel technique (4)
- increased blood supply to CT graft
- better adaptation and stability
- useful in recession on multiple teeth (can use single piece of donor tissue)
- but more challenging
What are 2 acellular dermal matrix derivatives? (2) And main contents? (1) Advantage (1)
Alloderm - human source
Mucoderm - derived from porcine dermis
main content: collagen
advantages: tx of multiple defects
What factors should be considered in root coverage procedures?
- quality of marginal tissues
- esthetic aspect of treated site
What are Bio-active Molecules? How are they made? Name the 2 types.
promotes healing
obtained by centrifugation of pt’s blood sample to sequester and concentrate platelets
Platelet Rich Plasma (PRP) & Platelet Rich Fibrin (PRF)
- PRP has anticoagulant (liquid - low density fibrin)) PRF doesn’t and is done at lower speed (jelly-like - high density fibrin)
How are Bio-active molecules usually used for perio surgery
PRP + Bone graft + GTR
(more things included to increase chances of regeneration - put bone graft into IP area, cover with GTR, bone graft acts as a scaffold are for short term but after it resorbs, bone must be replaced by pt’s own osteoblasts → GTR)
What are bone morphogenic proteins? Where can you get it from? Why do you need carriers and give some examples.
BMPs secreted by osteoblasts stimulate new bone formation (osteogenic)
native BMP is present in minute amounts (1mg/kg of bone), so need large amt of bone is needed to produce (cant be autogenous) → therefore, recombinant BMPs have been developed
BMPs needs a carrier to get effective bone initiation, ideal carrier still not found, cariers:
- Demineralised Bone Matrix
- Collagen
- Resorbable polymers
- Calcium phosphate materials
What are enamel matrix derivatives? E.g. Emdogain
derived from porcine tooth germ
contains amelogenin, a matrix protein produced by ameloblasts and reduced enamel epithelium of root sheaths (idea that tooth germ will have messages to re-produce structures such as cementum)
combination approaches often used e.g. can be used in sandwich technique or with mucoderm for recession coverage
