PERIODONTAL PLASTIC AND ESTHETIC SURGERY Definition Periodontal Plastic

PERIODONTAL PLASTIC AND ESTHETIC SURGERY

Definition Periodontal Plastic Surgery is defined as the procedures performed to correct the anatomical, developmental and traumatic deformities of gingiva and alveolar mucosa.

Terminology Periodontal Plastic Surgery was previously termed as Muco-Gingival surgery The term Periodontal Plastic Surgery was originally introduced by Miller in 1993. AAP world workshop 1996 renamed Muco Gingival Surgery as Periodontal Plastic Surgery.

Objectives To correct the problems associated with inadequate attached gingiva. To correct the problems associated with shallow vestibule. To correct the problems associated with high frenum attachment.

Indications of periodontal plastic surgery Periodontal prosthetic surgery Crown lengthening surgery Ridge augmentation surgery Esthetic surgical correction. Coverage of denuded root surface Reconstruction of papilla. Esthetic surgical correction around implants

Rationale of periodontal plastic surgery was previously predicated on the assumption that a minimum width of attached gingiva is essential to maintain optimum gingival health.

PROBLEMS ASSOCIATED WITH INADEQUATE WIDTH OF ATTACHED GINGIVA

Normal Gingiva

Gingival and periodontal structures

Problems Associated With Inadequate Width of Attached Gingiva 1. 2. 3. 4. Difficulty in maintaining Optimum Gingival Health. Improper plaque control. Difficulty in maintaining Optimum Gingival Health around abutment teeth. Inadequate keratinized tissue for placement of RPD.

Measurement of Width of Attached Gingiva Width of attached gingiva can be measured by subtracting pocket depth from the distance between free gingival margin to the mucogingival junction.

Measurement of Width of Attached Gingiva and Keratinized Gingiva

Advantages of Creating Adequate Width of Attached Gingiva 1. 2. 3. Proper plaque removal. Improved esthetics. Reduces inflammation around restored teeth.

Techniques For Increasing Width of Attached Gingiva 1. 2. 3. 4. 5. Free gingival autograft, Free connective tissue autograft, Apically positioned flap, Pedicle autograft, Subepithelial connective tissue autograft.

Problems Associated With Shallow Vestibule 1. 2. Improper plaque removal, Difficulty in placement of removable prosthesis.

SHALLOW VESTIBULE NORMAL VESTIBULAR DEPTH

Measurement of Vestibular Depth of vestibule is measured from gingival margin to the bottom of the vestibule.

Advantages of Creating Adequate Vestibular Depth 1. 2. 3. Proper plaque control. Proper tooth brushing. Proper placement of removable prosthesis.

TECHNIQUES VESTIBULAR DEEPENING (EDLAN- MEJCHAR’S) FENESTRATION OPERATION FREE SOFT TISSUE AUTOGRAFT

PROBLEMS ASSOCIATED WITH HIGH FRENUM IMPROPER PLAQUE REMOVAL TENSION ON THE FRENUM MAY TEND TO OPEN THE SULCUS

NORMAL FRENUM ATTACHMENT HIGH FRENUM ATTACHMENT

EXAMINATION OF HIGH FRENUM TENSION TEST IS PERFORMED BY PULLING THE LIPS : IN CASES OF HIGH FRENUM, THERE IS BLANCHING OF THE GINGIVA AND MOVEMENT OF GINGIVAL MARGIN ALONG WITH THE MOVEMENT OF CHEEKS AND THE LIPS

ADVANTAGES OF CORRECTING HIGH FRENUM ATTACHMENT 1. 2. 3. Proper plaque control. Reduces inflammation of the gingiva around teeth. Reduces progression of periodontal disease

TECHNIQUES FRENOTOMY FRENECTOMY

GINGIVAL RECESSION DEFINITION: EXPOSURE OF THE TOOTH BY THE APICAL MIGRATION OF THE GINGIVA EXPOSURE OF THE ROOT SURFACE BY AN APICAL SHIFT IN THE POSITION OF THE GINGIVA

NO GINGIVAL RECESSION IN RELATION TO MANDIBULAR CENTRAL INCISOR

ETIOLOGY FAULTY TOOTH BRUSHING( GINGIVAL ABRASION) TOOTH MALPOSITIONING. FRICTION FROM SOFT TISSUE (GINGIVAL ABLATION) GINGIVAL INFLAMMATION HIGH FRENUM ATTACHMENT

Periodontal Plastic Surgery

Periodontal Plastic Surgery

CLASSIFICATION OF GINGIVAL RECESSION SULLIVAN AND ATKIN’S • SHALLOW –NARROW • SHALLOW –WIDE • DEEP- NARROW • DEEP- WIDE

CLASSIFICATION OF GINGIVAL RECESSION

TECHNIQUES TO MANAGE GINGIVAL RECESSION FREE GINGIVAL AUTOGRAFT PEDICLE AUTOGRAFT FREE CONNECTIVE TISSUE AUTOGRAFT SUBEPITHELIAL CONNECTIVE TISSUE AUTOGRAFT GUIDED TISSUE REGENERATION

MILLER’S CLASSIFICATION

Millers Class I Recession

Miller Class I Recession Class I Marginal tissue recession which does not extend to the mucogingival junction No periodontal bone loss in the interdental area 100% root coverage

Millers Class II Recession

Millers Class II Recession Class II Marginal tissue recession which extends to or beyond the mucogingival junction No periodontal loss in the interdental area 100% root coverage

Millers Class III Recession

Millers Class III Recession � Marginal tissue recession which extends to or beyond the mucogingival junction � Bone or soft tissue loss in the interdental area or malpositioning of the teeth, preventing 100% root coverage � Partial root coverage

Millers Class IV Recession

Millers Class IV Recession Class IV Marginal tissue recession which extends to or beyond the mucogingival junction Severe bone or soft tissue loss in the interdental area and/or malpositioning of teeth No root coverage

Root Coverage Using Free Autogenous Gingival Grafts Indications All cases where root coverage is necessary except when a graft of sufficient thickness (1. 5 -2. 0 mm) cannot be harvested Contraindications Extensive gingival recession Esthetic cases

Root Coverage Using Free Autogenous Gingival Grafts Disadvantages Poor ability to provide blood supply to the graft for root coverage Exposed deep and large wound on the palatal mucosa Inferior esthetic results due to scarring Surgery required in 2 areas

preoperative

Incisions

Epithelial Surface Removed

Donor Site

Free Gingiva Graft Harvested

Graft Placed at Recipient Site

Root Coverage & Increase In Attached Gingiva Postoperatively

Connective Tissue Grafts 88% root coverage in areas of severe gingival recession Greater amount of root coverage and rate of complete coverage with the use of connective tissue grafts as compared to free gingival grafts

Root Coverage Using Connective Tissue Grafts Advantages High predictability Graft receives abundant blood supply from 2 sources Wound closed at palatal donor site after harvest of connective tissue graft Esthetically pleasing results Applicable for gingival recession on multiple teeth

Root Coverage Using Connective Tissue Grafts Disadvantages Technically demanding Gingivoplasty may be necessary postoperatively

Multiple Rcessions

Recepient Site Incisions

Reflection of Flap

Donor Site

CT Graft Placed at Recipient Site

Flap placed over ct graft & sutured

Donor site flap sutured back

Postoperative root coverage