Mucoginigival Therapy

• Definition:– Mucoginigival surgery: Periodontal surgical

procedures used to correct defects in the morphology, position, and/or amount of gingiva (AAP Glossary).

– Techniques are used to provide a functionally adequate zone of keratinized attached gingiva (Friedman, 1962).

Anatomy

• Attached gingiva:

The portion of the

gingiva that is tapered,

firm, dense, stippled,

and tightly bound to

the underlying

periosteum, tooth,

and bone.

• Width of AG differs in different areas of the mouth. Greatest in the incisor region (3.5-4.5 mm in the max, 3.3-3.9 mm in the man). Least width in the 1st premolar area (1.9 mm in the max, 1.8 mm in the man)

Anatomy

Literature Review

– No standard width of keratinized attached gingiva has been established.

– In people with good oral hygiene 1 mm or less may be sufficient for health (Lang and loe, 1972; Dorfman et al., 1980).

– Kirch et al (1986) and Wennstrom (1987) have shown that even a movable marginal tissue of alveolar mucosa can be maintained stable over a long period of time

– Trauma of prosthetic treatment (Maynard and Wilson, 1979; Ericsson and Lindhe, 1984)

– Orthodontic restoration (Maynard and Ochsenbein, 1975; Coatoam et al., 1981)

– Frenulum pull (Gottsgen, 1954; Gorman, 1967)

– Rapidly progressing recession (Baker and Seymour, 1976)

Literature Review

• Tissue barrier concept:– Goldman and Cohen (1979) outlined a “tissue

barrier” concept– They postulated that a dense collagenous band of

CT retards or obstructs the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa.

– They recommended increasing the zone of keratinized attached gingiva tissue to achieve an adequate tissue barrier (thick tissue).

Literature Review

Literature Review

• Wennstrom (1985) states,”A thin marginal tissue, in particular in the absence of underlying alveolar bone, will be at greater risk of recession since the plaque-induced inflammatory lesion may occupy and cause destruction of the entire CT portion of the gingiva”

Objectives

1- To create an adequate zone of attached keratinized gingiva

2- To eliminate pocket that extend beyond the mucogingival line

3- To eliminate muscle and frenulum pull

4- To deepen the vestibule

5- To cover denuded root surfaces for esthetics or hypersensitivity

6- To overcome the anatomic factors of tooth position, thin alveolar housing, and large prominent roots, which promote dehiscence and/or fenestration

7- To minimize recession during orthodontic movement

8- To overcome the trauma of prosthetic or restoration requiring subgingival placement

Objectives

9- To stabilize and maintain a healthy mucogingival complex

10- To correct areas of progressive gingival recession

11- To correct ridge deformities and undercuts

Objectives

Gingival Recession

• Causes (predisposing factors):

1- Minimal attached gingiva

2- Frenum pull

3- Tooth malposition • Precipitating factors:

1- Inflammation related to plaque

2- Improper brushing

3- Iatrogenic dental care

Classification

• Sullivan and Atkins (1968)– Shallow-narrow– Shallow-wide– Deep-narrow– Deep-wide

• Miller (1985)Class I: Marginal tissue

recession that does not extend to the mucogingival junction. There is no periodontal loss (bone or soft tissue) in the interdental area, and 100% root coverage can be anticipated.

Classification

Classification

• Miller (1985)Class II: Marginal

tissue recession that extend to or beyond the mucogingival junction. There is no periodontal loss (bone or soft tissue) in the interdental area, and 100% root coverage can be anticipated.

Classification

• Miller (1985)Class III: Marginal

tissue recession that extend to or beyond the mucogingival junction. Bone or soft tissue has been lost from the interdental area, partial root coverage can be anticipated

Classification

• Miller (1985)Class IV: Marginal

tissue recession that extend to or beyond the mucogingival junction. Sever bone or soft tissue has been lost from the interdental area, root coverage can not be attempted.

Procedures• Free gingival grafts

• Coronally positioned flap

• Subepithelial connective tissue graft

• Pedicle flap

• Semilunar flap

• Transpositional flap

• CT pedicle graft

• Guided tissue regeneration with membranes

Free Gingival Graft

• Advantages

1- High degree of predictability

2- Simplicity

3- Ability to treat multiple teeth at the same time

4- Can be preformed when keratinized gingiva adjacent to the involved area is insufficient

5- As the first step in a two-stage procedure for attaining root coverage

6- As a single step for attaining root coverage

• Disadvantages

1- Two operative sites

2- Compromised blood supply

3- Greater discomfort

4- Poor hemostasis

5- Retention of graft

Free Gingival Graft

• Factors:

1- Graft thickness (1.5 mm to 2 mm is recommended)

2- Suturing techniques

3- Entrapment of a blood clot between the graft and the roots, as well as the adjacent soft tissue recipient bed

4- Mechanical root preparation (Sc/Rp)

5- Flattening of the root surface with Sc and Rp or rotary instrumentation

6- Chemical root conditioning (citric acid and tetracycline)

Free Gingival Graft

• Contraindications

1- A perceptible mismatch in color between donor site and gingiva adjacent to recipient site

2- A lack of thick donor tissue

3- A class III or class IV recession defect

4- A root surface of excessive mesiodistal width coupled with interproximal tissue that is too narrow to support the blood supply

Free Gingival Graft

Free Gingival Graft

• Common reasons for graft failure:– use of root coverage (prominent roots, wide

areas of root exposure)– proper graft adaptation– adequate transfusion of the graft– graft movement (plasmatic diffusion)

Coronally Positioned Flap

• Indications:– Esthetic coverage of exposed roots– For tooth sensitivity

• Requirements:– adequate zone of keratinized gingiva

(>3mm)

Coronally Positioned Flap• Advantages:

– treatment of multiple areas of root exposure– no need for involvement of adjacent teeth– high degree of success– even if the procedure does not work, it does not

increase the existing problem

• Disadvantage– need for two surgical procedures if the zone of

keratinized gingiva is inadequate

Subepithelial Connective Tissue Graft

• Advantages

1- It is predictable for obtaining root coverage

2- The technique results in good gingival color match

3- The palatal donor site is less prone to bleeding, and healing is easier than FGG

4- The double blood supply created in this approach is advantageous

5- The surgeon’s ability to control the thickness is

greater than is possible with the FGG

• Indications

1- A lack of adequate donor tissue for a lateral sliding flap

2- The presence of root recession

3- The presence of isolated wide recession

4- The presence of multiple root recession

5- The presence of recession adjacent to an edentulous area requiring ridge augmentation

6- The presence of recession in an area where esthetics is often great concern

Subepithelial Connective Tissue Graft

Laterally Positioned Pedicle Graft

• Advantages:

1- One surgical site

2- Good vascularity of the pedicle flap

3- Ability to cover a denuded root surface• Disadvantages:

1- Limited by the amount of adjacent keratinized attached gingiva

2- Possibility of recession at the donor site

3- Dehiscence or fenestration at donor site

4- limited to one or two teeth

• Contraindications:

1- Presence of deep interproximal pockets

2- Excessive root prominence

3- Deep or extensive root abrasion or erosion

4- Significant loss of interproximal bone height

Laterally Positioned Pedicle Graft

• Advantages:

1- Does not require a secondary donor site

2- Reduce postoperative discomfort

3- The new tissue blend with the adjacent tissue, providing a highly esthetic result

Guided Tissue Regeneration

• Disadvantages:

1- Multiple defect can not be treated at the same surgical session

2- Root coverage is limited by the height of the interproximal bone.

3- The necessity of membrane removal 4 to 6 weeks after the initial surgery

Guided Tissue Regeneration

Guided Tissue Regeneration

• Indications:

1- To cover isolated root surface for single tooth with wide, deep, localized recession, 5 mm in width or depth or wider and deeper

2- For areas of root sensitivity