PERIODONTAL PLASTIC PERIODONTAL PLASTIC AND ESTHETIC AND ESTHETIC

SURGERYSURGERY

Dr Deepak ChopraDr Deepak Chopra

DefinitionDefinition

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

Terminology Terminology

Periodontal Plastic Surgery was previously Periodontal Plastic Surgery was previously termed as Muco-Gingival surgery termed as Muco-Gingival surgery

The term Periodontal Plastic Surgery was The term Periodontal Plastic Surgery was originally introduced by Miller in 1993. originally introduced by Miller in 1993.

AAP world workshop 1996 renamed Muco AAP world workshop 1996 renamed Muco Gingival Surgery as Periodontal Plastic Gingival Surgery as Periodontal Plastic Surgery. Surgery.

ObjectivesObjectives

To correct the problems associated with To correct the problems associated with inadequate attached gingiva. inadequate attached gingiva.

To correct the problems associated with To correct the problems associated with shallow vestibule.shallow vestibule.

To correct the problems associated with To correct the problems associated with high frenum attachment.high frenum attachment.

Indications of periodontal plastic Indications of periodontal plastic surgerysurgery

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

Rationale Rationale

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

PROBLEMS ASSOCIATED WITH PROBLEMS ASSOCIATED WITH INADEQUATE WIDTH OF INADEQUATE WIDTH OF

ATTACHED GINGIVAATTACHED GINGIVA

Normal GingivaNormal Gingiva

Gingival and periodontal structuresGingival and periodontal structures

Problems Associated With Problems Associated With Inadequate Width of Attached Inadequate Width of Attached

GingivaGingiva1.1. Difficulty in maintaining Optimum Difficulty in maintaining Optimum

Gingival Health.Gingival Health.

2.2. Improper plaque control.Improper plaque control.

3.3. Difficulty in maintaining Optimum Difficulty in maintaining Optimum Gingival Health around abutment teeth.Gingival Health around abutment teeth.

4.4. Inadequate keratinized tissue for Inadequate keratinized tissue for placement of RPD.placement of RPD.

Measurement of Width of Attached Measurement of Width of Attached GingivaGingiva

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

Measurement of Width of Attached Measurement of Width of Attached Gingiva and Keratinized Gingiva Gingiva and Keratinized Gingiva

Advantages of Creating Adequate Advantages of Creating Adequate Width of Attached GingivaWidth of Attached Gingiva

1.1. Proper plaque removal.Proper plaque removal.

2.2. Improved esthetics.Improved esthetics.

3.3. Reduces inflammation around restored Reduces inflammation around restored teeth.teeth.

Techniques For Increasing Width of Techniques For Increasing Width of Attached GingivaAttached Gingiva

1.1. Free gingival autograft,Free gingival autograft,

2.2. Free connective tissue autograft,Free connective tissue autograft,

3.3. Apically positioned flap,Apically positioned flap,

4.4. Pedicle autograft,Pedicle autograft,

5.5. Subepithelial connective tissue autograft.Subepithelial connective tissue autograft.

Problems Associated With Shallow Problems Associated With Shallow VestibuleVestibule

1.1. Improper plaque removal,Improper plaque removal,

2.2. Difficulty in placement of removable Difficulty in placement of removable prosthesis.prosthesis.

SHALLOW VESTIBULE

NORMAL VESTIBULAR

DEPTH

Measurement of Vestibular DepthMeasurement of Vestibular Depth

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

Advantages of Creating Adequate Advantages of Creating Adequate Vestibular DepthVestibular Depth

1.1. Proper plaque control.Proper plaque control.

2.2. Proper tooth brushing.Proper tooth brushing.

3.3. Proper placement of removable Proper placement of removable prosthesis.prosthesis.

TECHNIQUESTECHNIQUES

VESTIBULAR DEEPENING (EDLAN- VESTIBULAR DEEPENING (EDLAN- MEJCHAR’S)MEJCHAR’S)

FENESTRATION OPERATIONFENESTRATION OPERATION

FREE SOFT TISSUE AUTOGRAFTFREE SOFT TISSUE AUTOGRAFT

PROBLEMS ASSOCIATED WITH PROBLEMS ASSOCIATED WITH HIGH FRENUMHIGH FRENUM

IMPROPER PLAQUE REMOVALIMPROPER PLAQUE REMOVAL

TENSION ON THE FRENUM MAY TEND TENSION ON THE FRENUM MAY TEND TO OPEN THE SULCUSTO OPEN THE SULCUS

NORMAL FRENUM ATTACHMENT

HIGH FRENUM ATTACHMENT

EXAMINATION OF HIGH EXAMINATION OF HIGH FRENUMFRENUM

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

ADVANTAGES OF CORRECTING ADVANTAGES OF CORRECTING HIGH FRENUM ATTACHMENTHIGH FRENUM ATTACHMENT

1.1. Proper plaque control.Proper plaque control.

2.2. Reduces inflammation of the gingiva Reduces inflammation of the gingiva around teeth.around teeth.

3.3. Reduces progression of periodontal Reduces progression of periodontal diseasedisease

TECHNIQUESTECHNIQUES

FRENOTOMYFRENOTOMY

FRENECTOMYFRENECTOMY

GINGIVAL RECESSIONGINGIVAL RECESSION

DEFINITION:DEFINITION:

EXPOSURE OF THE TOOTH BY THE EXPOSURE OF THE TOOTH BY THE APICAL MIGRATION OF THE GINGIVAAPICAL MIGRATION OF THE GINGIVA

EXPOSURE OF THE ROOT SURFACE EXPOSURE OF THE ROOT SURFACE BY AN APICAL SHIFT IN THE POSITION BY AN APICAL SHIFT IN THE POSITION OF THE GINGIVAOF THE GINGIVA

NO GINGIVAL RECESSION GINGIVAL RECESSION IN RELATION TO MANDIBULAR CENTRAL INCISOR

ETIOLOGYETIOLOGY

FAULTY TOOTH BRUSHING( GINGIVAL FAULTY TOOTH BRUSHING( GINGIVAL ABRASION)ABRASION)

TOOTH MALPOSITIONING.TOOTH MALPOSITIONING.

FRICTION FROM SOFT TISSUE FRICTION FROM SOFT TISSUE (GINGIVAL ABLATION)(GINGIVAL ABLATION)

GINGIVAL INFLAMMATIONGINGIVAL INFLAMMATION

HIGH FRENUM ATTACHMENTHIGH FRENUM ATTACHMENT

Periodontal Plastic SurgeryPeriodontal Plastic Surgery

Periodontal Plastic SurgeryPeriodontal Plastic Surgery

CLASSIFICATION OF GINGIVAL CLASSIFICATION OF GINGIVAL RECESSIONRECESSION

SULLIVAN AND ATKIN’SSULLIVAN AND ATKIN’S

•SHALLOW –NARROWSHALLOW –NARROW•SHALLOW –WIDESHALLOW –WIDE•DEEP- NARROWDEEP- NARROW•DEEP- WIDEDEEP- WIDE

CLASSIFICATION OF GINGIVAL CLASSIFICATION OF GINGIVAL RECESSIONRECESSION

TECHNIQUES TO MANAGE TECHNIQUES TO MANAGE GINGIVAL RECESSIONGINGIVAL RECESSION

FREE GINGIVAL AUTOGRAFTFREE GINGIVAL AUTOGRAFT

PEDICLE AUTOGRAFTPEDICLE AUTOGRAFT

FREE CONNECTIVE TISSUE FREE CONNECTIVE TISSUE AUTOGRAFTAUTOGRAFT

SUBEPITHELIAL CONNECTIVE TISSUE SUBEPITHELIAL CONNECTIVE TISSUE AUTOGRAFTAUTOGRAFT

GUIDED TISSUE REGENERATIONGUIDED TISSUE REGENERATION

MILLER’S CLASSIFICATIONMILLER’S CLASSIFICATION

Millers Class I RecessionMillers Class I Recession

Miller Class I RecessionMiller Class I Recession

Class IClass I

Marginal tissue recession which doesMarginal tissue recession which does

not extend to the mucogingival junctionnot extend to the mucogingival junction

No periodontal bone loss in the No periodontal bone loss in the

interdental areainterdental area

100% root coverage100% root coverage

Millers Class II RecessionMillers Class II Recession

Millers Class II RecessionMillers Class II Recession

Class IIClass II

Marginal tissue recession which extendsMarginal tissue recession which extends

to or beyond the mucogingival junctionto or beyond the mucogingival junction

No periodontal loss in the interdental areaNo periodontal loss in the interdental area

100% root coverage100% root coverage

Millers Class III RecessionMillers Class III Recession

Millers Class III RecessionMillers Class III Recession

Marginal tissue recession which extendsMarginal tissue recession which extends

to or beyond the mucogingival junctionto or beyond the mucogingival junction

Bone or soft tissue loss in the interdental area Bone or soft tissue loss in the interdental area

or malpositioning of the teeth, preventing or malpositioning of the teeth, preventing

100% root coverage100% root coverage

Partial root coverage Partial root coverage

Millers Class IV RecessionMillers Class IV Recession

Millers Class IV RecessionMillers Class IV Recession

Class IVClass IV

Marginal tissue recession which extendsMarginal tissue recession which extends

to or beyond the mucogingival junctionto or beyond the mucogingival junction

Severe bone or soft tissue loss in theSevere bone or soft tissue loss in the

interdental area and/or malpositioning of teethinterdental area and/or malpositioning of teeth

No root coverageNo root coverage

Root Coverage Using FreeRoot Coverage Using FreeAutogenous Gingival GraftsAutogenous Gingival Grafts

IndicationsIndications

All cases where root coverage is necessaryAll cases where root coverage is necessary

except when a graft of sufficient thicknessexcept when a graft of sufficient thickness

(1.5-2.0 mm) cannot be harvested(1.5-2.0 mm) cannot be harvested

ContraindicationsContraindications

Extensive gingival recessionExtensive gingival recession

Esthetic casesEsthetic cases

Root Coverage Using FreeRoot Coverage Using FreeAutogenous Gingival GraftsAutogenous Gingival Grafts

DisadvantagesDisadvantages

Poor ability to provide blood supply to thePoor ability to provide blood supply to the

graft for root coveragegraft for root coverage

Exposed deep and large wound on theExposed deep and large wound on the

palatal mucosapalatal mucosa

Inferior esthetic results due to scarringInferior esthetic results due to scarring

Surgery required in 2 areasSurgery required in 2 areas

preoperativepreoperative

IncisionsIncisions

Epithelial Surface RemovedEpithelial Surface Removed

Donor SiteDonor Site

Free Gingiva Graft HarvestedFree Gingiva Graft Harvested

Graft Placed at Recipient SiteGraft Placed at Recipient Site

Root Coverage & Increase In Attached Root Coverage & Increase In Attached Gingiva PostoperativelyGingiva Postoperatively

Connective Tissue GraftsConnective Tissue Grafts

Connective Tissue GraftsConnective Tissue Grafts

88% root coverage in areas of severe88% root coverage in areas of severe

gingival recessiongingival recession

Greater amount of root coverage and rateGreater amount of root coverage and rate

of complete coverage with the use ofof complete coverage with the use of

connective tissue grafts as compared toconnective tissue grafts as compared to

free gingival graftsfree gingival grafts

Root Coverage UsingRoot Coverage UsingConnective Tissue GraftsConnective Tissue Grafts

AdvantagesAdvantages

High predictabilityHigh predictability

Graft receives abundant blood supply from 2 Graft receives abundant blood supply from 2

sourcessources

Wound closed at palatal donor site afterWound closed at palatal donor site after

harvest of connective tissue graftharvest of connective tissue graft

Esthetically pleasing resultsEsthetically pleasing results

Applicable for gingival recession on multiple Applicable for gingival recession on multiple

teethteeth

Root Coverage UsingRoot Coverage UsingConnective Tissue GraftsConnective Tissue Grafts

DisadvantagesDisadvantages

Technically demandingTechnically demanding

Gingivoplasty may be necessaryGingivoplasty may be necessary

postoperativelypostoperatively

Multiple RcessionsMultiple Rcessions

Recepient Site IncisionsRecepient Site Incisions

Reflection of FlapReflection of Flap

Donor SiteDonor Site

CT Graft Placed at Recipient SiteCT Graft Placed at Recipient Site

Flap placed over ct graft & suturedFlap placed over ct graft & sutured

Donor site flap sutured backDonor site flap sutured back

Postoperative root coveragePostoperative root coverage