Surgical procedures in fixed partial dentures / dentistry dental implants

SURGICAL PROCEDURES
IN FPD
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS
INTRODUCTION
GINGIVECTOMY AND GINGIVOPLASTY
METHODS OF INCREASING THE WIDTH OF ATTACHED
GINGIVA AND COVERAGE OF DENUDED ROOTS.
CROWN LENGTHNING
ROOT RESECTION AND HEMISECTION
RIDGE AUGMENTATION
BONE GRAFT MATERIALS AND MEMRANES USED FOR
GUIDED TISSUE BONE REGENERATION.
FRENECTOMY
ELECTRO SURGERY FOR GINGIVAL RETRACTION
CONCLUSION
REFRENCES www.indiandentalacademy.com

INTRODUCTION

1. Gingivectomy and Gingivoplasty
Gingivectomy – excisional removal of gingival tissue
for pocket reduction or elimination.
Gingivoplasty – reshaping of the gingiva to attain a
more physiologic contour.
Indications
- Presence of suprabony pockets
- An adequate zone of keratinized tissue
- Gingival enlargements
- Unaesthetic or asymmetrical gingival topography
- To facilitate restorative dentistry

Contraindications
- Inadequate width of keratinized tissue
- Pockets beyond mucogingival junction
- Presence of intrabony pockets

2. Width of attached gingiva
Goldman and Cohen (1979) – “ tissue barrier
concept” They postulated that a dense collagenous
band of connective tissue retards or obstucts the
spread of inflammation better than does loose fiber
arrangement of the alveolar mucosa.

Techniques
1. Free gingival autograft
Bjorn (1963)
- Advantages
1. High degree of predictability.
2. Ability to treat multiple teeth at the same time.
3. Can be performed when keratinized gingiva
adjacent to the involved site is insufficient.
4. Simplicity.
- Disadvantages
1. Two operative sites
2. Compromised blood supply
3. Greater discomfort

2. Laterally positioned pedicle graft
Grupe and Warren (1956)
- Advantages
1. One surgical site
2. Good vascularity of pedicle flap
3. Ability to cover a denuded root surface
- Disadvantages
1. Limited by the amount of adjacent keratinized
gingiva
2. Possibility of recession at donor site
3. Limited to one or two teeth with recession

3.Coronally displaced pedicle graft
- Advantages
1. No need for involvement of adjacent teeth.
2. High degree of success for gingival recession
and sensitivity.
- Disadvantages
1. Cannot be used if the zone of keratinized
gingiva is inadequate / two surgical
procedures may be required.

Since the results of a coronally displaced flap
are often not favourable owing to the
presence of insufficient keratinized gingiva the
following procedure can be performed to
increase the chances of success –
1. Gingival extension operation with free
autogenous graft.
2. After 2 months a coronally displaced flap
operation can be performed.

4. Subepithelial connective tissue graft
Langer and Langer (1985)
Single most effective way to achieve predictable root
coverage with a high degree of cosmetic enhancement.
- Advantages
1. Esthetics
2. Predictability
3. One step procedure
4. Minimum palatal trauma
5. Used for multiple teeth
- Disadvantage
1. High degree of skill
2. Complicated suturing

3. Crown lengthening procedure
It is a surgical procedure designed to increase
the extent of supragingival tooth structure for
restorative or aesthetic purposes by apically
positioning the the gingival margin,removing
supporting bone, or both.
- 2 types
1. Esthetic - to improve appearance
2. Functional – when the clinical crown is too
short to provide adequate retention without
restoration impinging on the biologic width.

Biologic Width
The biologic width is the apicocoronal distance
that the junctional epithelium and supra crestal
connective tissue (gingival ) fibres are attached to
the tooth.
Average measurement:2.04 mm
i.e The junctional epithelium – 0.97mm
The connective tissue attachment – 1.07mm

Why is the biologic width important?
The body maintains the biologic width as a stable
dimension. When the biologic width is encroached upon
and injured by the extension of restorative
preparations and materials into this area ,uncontrolled
inflammation may occur as the body tries to reestablish
this dimension.This ultimately results in gingival
recession and bone loss.www.indiandentalacademy.com

Esthetic Crown Lengthening

Functional Crown Lengthening

4. Furcation involvement
Classification
Glickman (1953)

 Treatment of furcation involvement
Grade I - Scaling
Root planing
Gingivectomy
Odontoplasty
Grade II - Odontoplasty
Osteoplasty
Tunneling
Root resection
Grafting
GTR

Grade III & Grade IV - Tunneling
Root resection
Grafting
GTR
Extraction

Root resection
- Indications
1. Grade II & Grade III involvement
2. Severe vertical bone loss involving one root
3. Endodontic failure
4. Extensive root caries
5. Root resorption
- Contraindications
1. Teeth with poor crown root ratio
2. Inadequate bone support on the roots to be
retained
3. Fused roots
4. Poor surgical accesswww.indiandentalacademy.com

Hemisection

5. Ridge Augmentation
Classification
Seibert (1983)
Class I
Class II
Class IIIwww.indiandentalacademy.com

1.Immediate ridge augmentation
-Performed at the time of tooth extraction
- Advantages
1. Eliminates need for multiple surgical interventions to
augment loss.
2. Over contouring of the edentulous ridge allows for later
gingivoplasty to optimize pontic to soft tissue relationship.
- Disadvantages
1. Pre surgical restorative planning must be done prior to
surgical procedure.
2. Flap management and survival over large augmentation
areas.

2. Onlay graft
- The Onlay graft is of value and predictable in
small areas.
- Limitations
1. Limited amount of donor material
2. Two surgical sites are necessary
3. Reliance of vascular perfusion at recepient site.
4. Unpredictable post operative tissue shrinkage.

3. Pouch technique
- Garber and Rosenberg (1981)
- Used for soft tissue ridge augmentation
- Usually for Class I type of defects

3. Roll technique
- Used for soft tissue ridge augmentation
- Class I defects

4. Ridge augmentation - improved technique
- Allen et al (1985)

5.Controlled tissue expansion
- Newer modality which assists in achieving excess
tissue
- Advantages
1. Generates sufficient tissue at defect site.
2. Good colour matching.
3. Avoids the need of multiple phases of flap transfer or a
residual defect with subsequent secondary intention healing.
- Disadvantages
1. Multiple office visits for gradual expansion of expander.
2. Possible infection.
3. Tissue necrosis as a result of overexpansion.
4. Perforation of the bag during suturing.

6. Bone graft materials and membranes
used for guided tissuebone regeneration
- Classification
I. Acc to the type of graft
1. Autograft – eg) iliac crest marrow,osseous
coagulum,bone swaging,bone from extraction
site,etc
2. Allograft – eg) FDBA.DFDBA
3. Alloplast – eg) bioactive silica based glass,non
resorbable hydroxyapatite.
4. Xenograft – eg) bovine and procine matrix
proteins.

II. Acc to inductive potential
1. Osteoinductive - eg) hip marrow,osseous
coagulum,bone from extraction
site,tuberosity,DFDBA,etc.
2. Osteoconductive - eg) FDBA,DFDBA
3. Osteoneutral - eg) tricalcium phosphate
• Types of membranes
1. Resorbable – eg)Guidor membrane (polylactic
acid resorbable membrane)
2. Nonresorbable – eg)Gore-tex membrane
(polytetrafluoroethylene membrane)

Guided tissue regeneration
- Indications
1. Grade II furcation
2. 2-3 walled vertical defects
3. Good oral hygiene
4. Adequate keratinized gingiva
Contraindications
1. Horizontal defect
2. Flap perforation
3. Very severe defect – minimal remaining
periodontium

7. Frenectomy

8. Electrosurgery for Gingival
Retraction

Conclusion

References
1) Rosensteil “Contemporary fixed
prosthodontics”, 3rd
Edition.
2) Shillengburg “Fundamentals of fixed
prosthodontics”, 3rd
Edition.
3) Caranza “Clinical periodontology”, 8th
Edition.
4) Cohen “Atlas of cosmetic and reconstructive
periodontal surgery”, 2nd
Edition.
5) Francis G. Serio “Manual of clinical
periodontics”.
6) Wilson “Advances in periodontics”.
7) Dr. Ratnadeep Patil “Esthetic dentistry - an
artists science”.
8) “Extension of clinical crown length”, JPD,
55;547: 1986.www.indiandentalacademy.com

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Surgical procedures in fixed partial dentures / dentistry dental implants

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