Se ha denunciado esta presentación.
Utilizamos tu perfil de LinkedIn y tus datos de actividad para personalizar los anuncios y mostrarte publicidad más relevante. Puedes cambiar tus preferencias de publicidad en cualquier momento.
Periodontal plastic
surgery-1
PRESENTER
DR. REBICCA RANJIT
IIIrd YEAR RESIDENT
Mucogingival therapy: A general term used to describe
periodontal treatment involving procedures for corrections
of defect...
A more specific term;
Introduced by Nathan Friedman in 1957.
Surgical procedures designed to preserve gingiva, remove
abbe...
Periodontal plastic surgery is defined as the surgical
procedures performed to correct or eliminate anatomic,
developmenta...
Mucogingival surgery,
Nathan Friedman, 1957
Periodontal plastic surgery,
Miller, 1993
World Workshop in Clinical
Periodont...
Periodontal plastic surgery - broadened to include following areas
Periodontal prosthetic corrections
Crown lengthening
Ri...
The 3 objectives of periodontal plastic surgery:
Problem associated with:
Aberrant
frenum
Shallow
vestibule
Attached
gingi...
ATTACHED
GINGIVA
It is the distance between the projection on the external
surface of bottom of gingival sulcus or periodontal pocket
(A) ...
Width of attached gingiva is greatest at the incisors and least
at
premolars of facial aspect (Bowers)
Facial aspect Inci...
Function
 Prevents apical spread of inflammation.
 Deflects food away from gingival margin.
 Braces gingiva firmly agai...
METHODS TO MEASURE
THE WIDTH OF ATTACHED GINGIVA
 AG = Total width of gingiva  Depth of sulcus
• This is done by stretching the lip or cheek to demarcate the
mucogingiva...
Pushing the adjacent mucosa coronally with a dull
instrument helps in demarcating mucogingival
junction
Roll test
Histochemically , by application of Schiller’s or Lugol’s potassium iodine
solution which stains glycogen content.
 Lugo...
Tension test
Tension applied to lip in outward, downward/upward, & lateral
directions.
Gingival margin is observed
Any mov...
Adequate attached gingiva??
VARIOUS AUTHORS ADEQUATE ATTACHED GINGIVA
Corn, 1962 > 3mm (Keratinized gingiva)
Bowers, 1963 <1 mm
Friedman, 1962; De
Tre...
TISSUE BARRIER CONCEPT
 Outlined by Goldman & Cohen, 1979
 Postulated that:- A dense collagenous band of CT retards or
o...
WIDENING OF ATTACHED GINGIVA
accomplishes following 4 objectives:
a) Enhances plaque removal around gingival margin
b) Imp...
SURGICAL TECHNIQUES TO
INCREASE THE WIDTH OF
ATTACHED GINGIVA
Minimal attached gingiva with adequate vestibular depth
may ...
SURGICAL TECHNIQUES TO
INCREASE THE WIDTH OF ATTACHED
GINGIVA
Gingival augmentation
apical to recession
Gingival augmentat...
Gingival augmentation apical to
recessionFree
connective
tissue
autograft
Apically
reposition
ed flap
Free gingival
autogr...
Free gingival
autograft
 Introduced by Bjorn, 1963
 Nabers introduced the term “Free gingival graft”, 1966
 Described b...
Classic technique
Step 1: Prepare the recipient site
The recipient site prepared by incising at the existing
mucogingival ...
An aluminum foil template of the recipient site
can be made to be used as a pattern for the
graft.
Palate
This is the area...
Step 2: Obtain the graft from the donor site:
Place the template over the donor site, and make a shallow
incision around i...
The ideal thickness of a graft = 1.0 - 1.5
mm
• Peripheral layer is jeopardized due to
excessive tissue that separates it ...
Step 3: Transfer and immobilize the graft.
• Position the graft and adapt it firmly to the recipient site.
• A space betwe...
 The graft must be immobilized (Any movement interferes with
healing.)
 Avoid excessive tension(Can distort the graft fr...
Step 4: Protect the donor site.
with a periodontal dressing for 1
week
A modified Hawley retainer is useful
to cover the p...
Gingival augmentation apical to
recession
Free gingival
autograft
Bjorn,1963
Classic technique Variant technique
Accordion...
Accordion technique
• Rateitschak et al
• Expansion of the graft by alternate incisions in
opposite sides of the graft.
• ...
Gingival augmentation apical to
recession
Free gingival
autograft
Bjorn,1963
Classic technique Variant technique
Accordion...
Strip technique
• Developed by Han et al.
• 2/3 strips of gingival donor tissue about 3 to 5 mm wide and long
enough to co...
Gingival augmentation apical to
recession
Free gingival
autograft
Bjorn,1963
Classic technique Variant technique
Accordion...
A deep strip graft (3 to 4 mm thick) is taken from the palate
Placed between two wet tongue depressors & split it longitud...
Healing of free soft tissue grafts placed entirely on a connective tissue
recipient bed were studied in rhesus monkeys by ...
• Thin layer of exudate between graft & recipient
bed
• Grafted tissue survive with an avascular
Plasmatic
circulation fro...
Alternative Donor Tissue:- acellular dermal matrix (ADM)
• Acellular. non-immunogenic scaffolds which heals by repopulatio...
Free connective
tissue autograft
Originally described by Alan Edel, 1974
Donor connective tissue is obtained from the unde...
Free connective tissue
autograft
Step 1: Prepare the recipient site
Step 2: Obtain the graft from the donor site
Donor connective tissue is obtained from the undersurface of the
palatal flap...
Step 3: Transfer and immobilize the graft.
Advantage
 Connective tissue carries the genetic message for the
overlying epithelium to become keratinized.
Better color...
Gingival augmentation apical to
recessionApically
repositione
d flap
Can be used for pocket eradication, widening the
zone...
The edge of the flap may be located in 3 positions in relation to the
bone:
3. 2mm short of the crest:
Produces the most d...
SURGICAL TECHNIQUES TO
INCREASE THE WIDTH OF ATTACHED
GINGIVA
Gingival augmentation
apical to recession
Gingival augmentat...
SURGICAL
NON-
SURGICAL
NON-SURGICAL
Periodontal
management
Orthodontic
management
Esthetic
dentistry
Prosthodontic
management
• Desensitizing
too...
New resin-based
gingival-colored composites
Gingival
veneer
SURGIC
AL
Pedicle soft-tissue graft procedures:
a) Rotational flap procedures
(laterally sliding flap, double papilla flap...
Free gingival autograft Miller
Free connective tissue autograft
Levine,1991
Pedicled autograft:- Laterally displaced /Coro...
Step 1: Root planning
Step 2: Prepare the recipient site:
• Horizontal incision in IDP at right angles
• Divergent vertica...
The difference between this technique and the free gingival
autograft is that the donor tissue is
Free connective tissue a...
Pedicle Autograft
Laterally (Horizontally) Displaced Pedicle Flap:
• Originally described by Grupe and Warren in 1956.
• To cover isolated, ...
Step 1: Prepare the recipient site. Epithelium around the
denuded root surface is removed followed by thorough SRP.
Step 2...
A releasing incision (a short oblique
incision into the alveolar mucosa at
the distal corner of the flap, in the
direction ...
• Incomplete root coverage
• Recession in the donor area
• Need for an adequate donor area adjacent to the area
to be trea...
Healing of pedicle soft tissue grafts by Wilderman & Wentz (1965)
in dogs.
Adaptation
stage (0–4
days)
Proliferation stage...
Epithelium covering the transplanted tissue flap
starts to proliferate and reaches contact with the
tooth surface
at the c...
Double-Papilla Procedure
Introduced by Waienberg, 1964
Modified by Cohen & Ross, 1968
indicated in Millers Class II recess...
Purpose :- To create a split-thickness flap in the area apical to
the denuded root and position it coronally to cover
the ...
First Technique
• 2 vertical incisions extending beyond the mucogingival
junction.
• An internal bevel incision to elimina...
Variations to First Technique
(In cases with insufficient keratinized gingiva apical to the
recession)
Double-step procedu...
Second Technique:
2)Semilunar coronally repositioned flap
Tarnow (To cover isolated denuded root surfaces or on several
ad...
Semilunar incision made following the
curvature of the receded gingival margin &
ending about 2-3 mm short of tip of papil...
 Indication:
• Where the recession is not extensive (3 mm):-Provides 2
to 3 mm of root coverage
• Facial gingival biotype...
Larger and multiple defects with good vestibular depth and gingival
thickness to allow a split-thickness flap to be elevat...
Partial-thickness flap with:
• Horizontal incision 2 mm away from the tip of
papilla
• 2 vertical incisions 1-2 mm away fro...
Bilaminar reconstruction of the gingiva using both free and pedicle layers to
preserve graft viability over denuded root s...
Wennstorm & Zucchelli, 1996
GTR Technique for Root Coverage Pini-Prato et
al, 1992
Full-thickness flap is reflected to the
MGJ, continuing as a partia...
Flap is then positioned coronally & sutured.
4 weeks later, a small envelope flap is
performed, and the membrane is carefu...
GTR technique better when the recession is > 4.98 mm apicocoronally.
Coronally displaced flap Vs GTR technique by Pini Pra...
Reported:-
• 3.66 mm of new connective tissue
attachment
• 2.48 mm of new cementum and
• 1.84 mm of bone growth
Pouch & Tunnel Technique (Coronally Advanced Tunnel
Technique)
• Effective for the anterior maxillary area ; with adequate...
Patient preparation: Plaque control instruction; SRP before the surgical
procedure.
Composite material stops are placed at...
Small, contoured blades & mini curettes are used to create the recipient
pouches and tunnels.
Dissect the connective tissu...
Size of the pouch (including the area of the denuded root surface, is
measured so that an equivalent size donor connective...
• Tissue is gently pushed into pouch & tunnel with tissue forceps & packing
instrument.
Mattress suture will help maintain...
The entire gingivopapillary complex (buccal gingiva with the
underlying connective tissue graft, and papillae) is coronall...
• Minimize incisions & the reflection of flap.
• Provides abundant blood supply to the donor tissue,
• Placement of donor ...
• Requires 2 surgical sites;
• Delicate harvesting of graft;
• Prolonged healing time.
DISADVANTAG
ES
VISTA Technique
Vestibular Incision Subperiosteal Tunnel Access
Pin hole surgical technique: John C.
Chao
 Using PST, mean % defect coverage was 94%.
CONCLUSION
New techniques are constantly being developed and are slowly being
incorporated into periodontal practice. Crit...
BIBLIOGRAPHY…..
 Newman, Takei, Fermin A Carranza. Clinical periodontology, 12th Edition.
 Jan Lindhe. Clinical Periodon...
• Pini Prato GP, Tinti C, Vincenzi G, Magnani C, Cortellini , Clauser C. Guided
tissue regeneration versus mucogingival su...
• Kumar PM, Reddy NR, Kumar SS, Chakrapani S. Double papilla flap
technique for dual purpose. J Orofac Sci 2012;4:75-8.
• H...
• Edel A. Clinical evaluation of free connective tissue grafts used to increase
the width of keratinized gingiva. J Clin P...
Periodontal plastic surgery
Periodontal plastic surgery
Periodontal plastic surgery
Periodontal plastic surgery
Próxima SlideShare
Cargando en…5
×
Próxima SlideShare
Periodontal plastic surgery
Siguiente

231

Compartir

Periodontal plastic surgery


Periodontal plastic surgery-1
PRESENTER
DR. REBICCA RANJIT
IIIrd YEAR RESIDENT



































































































Libros relacionados

Gratis con una prueba de 30 días de Scribd

Ver todo

Audiolibros relacionados

Gratis con una prueba de 30 días de Scribd

Ver todo

Periodontal plastic surgery

  1. 1. Periodontal plastic surgery-1 PRESENTER DR. REBICCA RANJIT IIIrd YEAR RESIDENT
  2. 2. Mucogingival therapy: A general term used to describe periodontal treatment involving procedures for corrections of defects in morphology, position, &/or amount of soft tissues & underlying bone support at teeth & implants. GPT-2001
  3. 3. A more specific term; Introduced by Nathan Friedman in 1957. Surgical procedures designed to preserve gingiva, remove abberant frenum, or muscle attachments, and increase the depth of vestibule. Mucogingival surgery:
  4. 4. Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic or disease induced defects of the gingiva, alveolar mucosa or bone. 1996, World Workshop in Clinical Periodontics renamed mucogingival surgery as “periodontal plastic surgery,” which was originally proposed by Miller in 1993
  5. 5. Mucogingival surgery, Nathan Friedman, 1957 Periodontal plastic surgery, Miller, 1993 World Workshop in Clinical Periodontics,1996 Periodontal & Reconstructive surgery
  6. 6. Periodontal plastic surgery - broadened to include following areas Periodontal prosthetic corrections Crown lengthening Ridge augmentation Esthetic surgical corrections Esthetic surgical correction around implants Reconstruction of the papillae Surgical exposure of unerupted teeth for orthodontics Lip repositioning Gingival augmentation Coverage of the denuded root surface
  7. 7. The 3 objectives of periodontal plastic surgery: Problem associated with: Aberrant frenum Shallow vestibule Attached gingiva4. Esthetic surgical therapy 5. Tissue engineering
  8. 8. ATTACHED GINGIVA
  9. 9. It is the distance between the projection on the external surface of bottom of gingival sulcus or periodontal pocket (A) & mucogingival junction (B). Firm, resilient & tightly bound to underlying periosteum & is continuous with marginal gingiva.
  10. 10. Width of attached gingiva is greatest at the incisors and least at premolars of facial aspect (Bowers) Facial aspect Incisors (maximum) Ist Premolars (minimum) Maxilla 3.5-4.5 mm 1.9mm Mandible 3.3-3.9mm 1.8mm  Width = Total width of gingiva - Depth of sulcus AB = BC - AC
  11. 11. Function  Prevents apical spread of inflammation.  Deflects food away from gingival margin.  Braces gingiva firmly against teeth.  Acts as buffer between 2 moveable mucosa  Bear the compressive & shear forces during mastication  Prevents transmission of frenal pull.
  12. 12. METHODS TO MEASURE THE WIDTH OF ATTACHED GINGIVA
  13. 13.  AG = Total width of gingiva  Depth of sulcus • This is done by stretching the lip or cheek to demarcate the mucogingival line while the pocket is being probed. • The amount of attached gingiva is considered to be insufficient when stretching of the lip or cheek induces movement of the free gingival margin. Visual method
  14. 14. Pushing the adjacent mucosa coronally with a dull instrument helps in demarcating mucogingival junction Roll test
  15. 15. Histochemically , by application of Schiller’s or Lugol’s potassium iodine solution which stains glycogen content.  Lugol's iodine helps to better visualize the mucogingival junction in the mouth. Alveolar mucosa has a high glycogen content that gives a positive iodine reaction. Histochemical staining method Fasske and Morgenroth
  16. 16. Tension test Tension applied to lip in outward, downward/upward, & lateral directions. Gingival margin is observed Any movement of the free gingiva is recorded as representing a positive response to the tension test
  17. 17. Adequate attached gingiva??
  18. 18. VARIOUS AUTHORS ADEQUATE ATTACHED GINGIVA Corn, 1962 > 3mm (Keratinized gingiva) Bowers, 1963 <1 mm Friedman, 1962; De Trey & Bernimoulin, 1980 Gingiva that is compatible to gingival health & that prevents retraction of gingival margin during movement of alveolar mucosa Lang & Loe, 1972 2mm
  19. 19. TISSUE BARRIER CONCEPT  Outlined by Goldman & Cohen, 1979  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 attached gingiva to achieve an adequate tissue barrier (thick tissue).
  20. 20. WIDENING OF ATTACHED GINGIVA accomplishes following 4 objectives: a) Enhances plaque removal around gingival margin b) Improves esthetics c) Reduces inflammation around restored teeth d) Gingival margin binds better around teeth & implants with attached gingiva
  21. 21. SURGICAL TECHNIQUES TO INCREASE THE WIDTH OF ATTACHED GINGIVA Minimal attached gingiva with adequate vestibular depth may not require surgical correction
  22. 22. SURGICAL TECHNIQUES TO INCREASE THE WIDTH OF ATTACHED GINGIVA Gingival augmentation apical to recession Gingival augmentation Coronal to the recession (root coverage)
  23. 23. Gingival augmentation apical to recessionFree connective tissue autograft Apically reposition ed flap Free gingival autograft Bjorn,1963 Alan Edel, 1974 Introduced by Nabers, Coined by Friedman Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
  24. 24. Free gingival autograft  Introduced by Bjorn, 1963  Nabers introduced the term “Free gingival graft”, 1966  Described by Sullivan & Atkins, 1968
  25. 25. Classic technique Step 1: Prepare the recipient site The recipient site prepared by incising at the existing mucogingival junction with a #15 blade to the desired depth with periosteum left intact. To prepare a firm connective tissue bed to receive the graft.
  26. 26. An aluminum foil template of the recipient site can be made to be used as a pattern for the graft. Palate This is the area where the thickest tissue can be found (Reiser et al. 1996) DONOR SITE • Palate, • Maxillary tuberosity • Edentulous ridges, • Retromolar areas, and • Wide zones of gingiva; • Operculum over an erupting tooth
  27. 27. Step 2: Obtain the graft from the donor site: Place the template over the donor site, and make a shallow incision around it with a #15 blade Insert the blade to the desired thickness at one edge of the graft. Elevate the edge & hold it with tissue forceps Continue to separate the graft with the blade, lifting it gently as separation progresses to provide visibility. A partial-thickness graft (epithelium + a thin layer of underlying connective tissue) 5 to 6 mm
  28. 28. The ideal thickness of a graft = 1.0 - 1.5 mm • Peripheral layer is jeopardized due to excessive tissue that separates it from new circulation and nutrients. • Also creates a deeper wound at the donor site, with the possibility of injuring major palatal arteries (Thin enough to permit diffusion of fluid from the recipient site, which is essential in the immediate post-transplant period) Too thin graft Necrosis and exposure of the recipient site. Too thick graft
  29. 29. Step 3: Transfer and immobilize the graft. • Position the graft and adapt it firmly to the recipient site. • A space between the graft and the underlying tissue (dead space) impairs vascularization and jeopardizes the graft. • Suture the graft at the lateral borders and to the periosteum to secure it in position.
  30. 30.  The graft must be immobilized (Any movement interferes with healing.)  Avoid excessive tension(Can distort the graft from the underlying surface.)  Avoid trauma to the graft. (Tissue forceps should be used delicately)  Minimum number of sutures used to avoid unnecessary tissue perforation PRECAUTIONS
  31. 31. Step 4: Protect the donor site. with a periodontal dressing for 1 week A modified Hawley retainer is useful to cover the pack on the palate and over edentulous ridges.
  32. 32. Gingival augmentation apical to recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique attempt to minimize the donor site morbidity
  33. 33. Accordion technique • Rateitschak et al • Expansion of the graft by alternate incisions in opposite sides of the graft. • It increases the donor graft tissue by changing the configuration of the tissue.
  34. 34. Gingival augmentation apical to recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
  35. 35. Strip technique • Developed by Han et al. • 2/3 strips of gingival donor tissue about 3 to 5 mm wide and long enough to cover the entire length of the recipient site. • These strips are placed side by side to form one donor tissue and sutured on the recipient site. • The area is then covered with aluminum foil and surgical dressing.
  36. 36. Gingival augmentation apical to recession Free gingival autograft Bjorn,1963 Classic technique Variant technique Accordion technique Strip technique Combination epithelial- connective tissue strip technique
  37. 37. A deep strip graft (3 to 4 mm thick) is taken from the palate Placed between two wet tongue depressors & split it longitudinally with a sharp #15 blade. Both will be used as free grafts. Split into and Advantage:- The minimal donor site wound obtained by two donor tissues from one site. Combination technique superficial epithelial-connective tissue strip deeper pure connective strip.
  38. 38. Healing of free soft tissue grafts placed entirely on a connective tissue recipient bed were studied in rhesus monkeys by Oliver et al. (1968) and Nobuto et al. (1988). Healing can be divided into three phases:- Tissue maturation phase (from 11–42 days). Revascularizatio n phase (from 2–11 days) Initial phase (from 0–3 days)
  39. 39. • Thin layer of exudate between graft & recipient bed • Grafted tissue survive with an avascular Plasmatic circulation from the recipient bed. • Epithelium of FGG Degenerates & desquamates • Anastomoses established between blood vessels of recipient bed & those in the grafted tissue. • Circulation of blood is re-established in the pre-existing blood vessels of the graft. • Fibrous union. • Re-epithelialization of the graft. • No. of blood vessels in transplant gradually reduced. • After 14 days, vascular system appears normal. • Epithelium matures with formation of keratin layer.
  40. 40. Alternative Donor Tissue:- acellular dermal matrix (ADM) • Acellular. non-immunogenic scaffolds which heals by repopulation & revascularization • Derived from donated human skin; multistep proprietary process that removes epithelium with intact basement membrane to promote faster reepithelialization. RCTs have demonstrated outcomes with ADM equivalent to palatal donor tissue in treatment of gingival recession.
  41. 41. Free connective tissue autograft Originally described by Alan Edel, 1974 Donor connective tissue is obtained from the undersurface of the palatal flap Sutured back; therefore healing is by first intention
  42. 42. Free connective tissue autograft Step 1: Prepare the recipient site
  43. 43. Step 2: Obtain the graft from the donor site Donor connective tissue is obtained from the undersurface of the palatal flap Sutured back; therefore healing is by first intention
  44. 44. Step 3: Transfer and immobilize the graft.
  45. 45. Advantage  Connective tissue carries the genetic message for the overlying epithelium to become keratinized. Better color match of the grafted tissue to the adjacent areas. Improved esthetics can be achieved  Healing is by first intention: Less discomfort postoperatively at the donor site.
  46. 46. Gingival augmentation apical to recessionApically repositione d flap Can be used for pocket eradication, widening the zone of attached gingiva,or both An internal bevel incision (about 1 mm from the crest of gingiva) made Crevicular incisions followed by initial elevation of flap Interdental incision given Vertical incisions are made extending beyond the mucogingival junction
  47. 47. The edge of the flap may be located in 3 positions in relation to the bone: 3. 2mm short of the crest: Produces the most desirable (a firm, tapered gingival margin) gingival contour and the same post-treatment level of gingival attachment as obtained by placing the flap at the crest of the bone. 2. At the level of the crest: satisfactory gingival contour, provided that the flap is adequately thinned 1. Slightly coronal to the crest of the bone: Preserve the attachment of supracrestal fibers; Result in thick gingival margins and interdental papillae with Deep sulci with the risk of recurrent pockets
  48. 48. SURGICAL TECHNIQUES TO INCREASE THE WIDTH OF ATTACHED GINGIVA Gingival augmentation apical to recession Gingival augmentation Coronal to the recession (root coverage)
  49. 49. SURGICAL NON- SURGICAL
  50. 50. NON-SURGICAL Periodontal management Orthodontic management Esthetic dentistry Prosthodontic management • Desensitizing toothpastes/agents • SRP • Polishing (Aimetti et al,2005) Gingival veneer:- pink autocure and heat-cured acrylics, porcelains, composite resins thermoplastic acrylics, silicone-based soft materials. New resin-based gingival-colored composites
  51. 51. New resin-based gingival-colored composites
  52. 52. Gingival veneer
  53. 53. SURGIC AL Pedicle soft-tissue graft procedures: a) Rotational flap procedures (laterally sliding flap, double papilla flap, oblique rotated flap); b) Advanced flap procedures (Coronally repositioned flap, Semilunar coronally repositioned flap); c)Regenerative procedures (With barrier membrane or application of enamel matrix Free soft-tissue graft procedures: a) Epithelialized graft; b) Sub-epithelial connective tissue graft
  54. 54. Free gingival autograft Miller Free connective tissue autograft Levine,1991 Pedicled autograft:- Laterally displaced /Coronally advanced flap Sub-epithelial connective tissue graft Langer & Langer, 1985 GTR with pedicled soft tissue graft Pini Prato et al,1992 Pouch & tunnel technique Azzi et al Pinhole surgical technique John C. Chao SURGIC AL
  55. 55. Step 1: Root planning Step 2: Prepare the recipient site: • Horizontal incision in IDP at right angles • Divergent vertical incisions made at the line angles of tooth to be covered, creating a partial-thickness flap to at least 5 mm apical to the receded area Steps 3 : Obtain the graft from the donor site: • 1-1.5mm partial-thickness graft harvested from palate Step 4: Transfer & immobilize the graft: • Position the graft and adapt it firmly to the recipient site; Avoid movement, excessive tension & trauma to the graft ; Cover the graft. Free gingival autograft Miller 5 mm
  56. 56. The difference between this technique and the free gingival autograft is that the donor tissue is Free connective tissue autograft Levine,199 connective tissue.
  57. 57. Pedicle Autograft
  58. 58. Laterally (Horizontally) Displaced Pedicle Flap: • Originally described by Grupe and Warren in 1956. • To cover isolated, denuded root surfaces • Criteria:- Donor site with adequate width of attached gingiva, minimal bone loss, & without dehiscence/fenestration. :- Adequate vestibular depth
  59. 59. Step 1: Prepare the recipient site. Epithelium around the denuded root surface is removed followed by thorough SRP. Step 2: Prepare the flap. Partial-thickness flap > full-thickness Rapid healing at the donor site Reduces the risk of loss of facial bone height. Only if gingiva is thin; But some loss of radicular bone (0.5mm) & recession (1.5mm)
  60. 60. A releasing incision (a short oblique incision into the alveolar mucosa at the distal corner of the flap, in the direction of the recipient site) to avoid tension Corn,1964
  61. 61. • Incomplete root coverage • Recession in the donor area • Need for an adequate donor area adjacent to the area to be treated. DISADVANTAG ES
  62. 62. Healing of pedicle soft tissue grafts by Wilderman & Wentz (1965) in dogs. Adaptation stage (0–4 days) Proliferation stage (4–21 days) Attachment stage (27–28 days) Maturation stage
  63. 63. Epithelium covering the transplanted tissue flap starts to proliferate and reaches contact with the tooth surface at the coronal edge of the flap after a few days Fibrin layer between the root surface and the flap is invaded by connective tissue proliferating from the subsurface of the flap. 6–10 days: a layer of fibroblasts in apposition to root which differentiate into cementoblasts Thin collagen fibers formed adjacent to the root surface. Epithelium proliferates apically along root surface Thin collagen fibers become inserted in a layer of new cementum. Continuous formation of collagen fibers. After 2–3 months bundles of collagen fibers insert into the cementum layer on the curetted root surface
  64. 64. Double-Papilla Procedure Introduced by Waienberg, 1964 Modified by Cohen & Ross, 1968 indicated in Millers Class II recession with inadequate attached gingiva but presence of sufficient width and length of interdental papilla on both sides of the area of gingival recession. Complication :- • Necrosis of the flap • Swelling & bruising at the recipient site • Deep & narrow cleft at middle surface of the root
  65. 65. Purpose :- To create a split-thickness flap in the area apical to the denuded root and position it coronally to cover the root. Coronally Displaced Flap 2 techniques are available for this purpose
  66. 66. First Technique • 2 vertical incisions extending beyond the mucogingival junction. • An internal bevel incision to eliminate diseased pocket wall. • Elevate split thickness flap followed by SRP Suture the flap at a level coronal to the pretreatment position. Periodontal dressing
  67. 67. Variations to First Technique (In cases with insufficient keratinized gingiva apical to the recession) Double-step procedure (Initially by Harvey, 1970 Bernimoulin et al, 1973):- Gingival augmentation procedure with free autogenous graft 2 months Coronally positioned graft
  68. 68. Second Technique: 2)Semilunar coronally repositioned flap Tarnow (To cover isolated denuded root surfaces or on several adjoining teeth)
  69. 69. Semilunar incision made following the curvature of the receded gingival margin & ending about 2-3 mm short of tip of papillae. Split-thickness dissection coronally from the incision, and connect it to an intrasulcular incision. Tissue will collapse coronally, covering the denuded root
  70. 70.  Indication: • Where the recession is not extensive (3 mm):-Provides 2 to 3 mm of root coverage • Facial gingival biotype is thick. • It is successful for the maxilla,  Not recommended for the mandibular dentition Semilunar coronally repositioned flap
  71. 71. Larger and multiple defects with good vestibular depth and gingival thickness to allow a split-thickness flap to be elevated. Adjacent to the denuded root surface, the donor connective tissue is sandwiched between the split flap. Subepithelial Connective Tissue Graft (Langer & Langer in 1985)
  72. 72. Partial-thickness flap with: • Horizontal incision 2 mm away from the tip of papilla • 2 vertical incisions 1-2 mm away from gingival margin of the adjoining teeth Favorable esthetic result Primary healing of donor site
  73. 73. Bilaminar reconstruction of the gingiva using both free and pedicle layers to preserve graft viability over denuded root surfaces. Increased blood supply over the donor tissue & the gingival margin is thickened for better marginal stability. A variant of the subepithelial connective tissue graft, called a subpedicle (bilaminar) connective tissue graft, was described by Nelson in 1987. SECTG + Double papilla
  74. 74. Wennstorm & Zucchelli, 1996
  75. 75. GTR Technique for Root Coverage Pini-Prato et al, 1992 Full-thickness flap is reflected to the MGJ, continuing as a partial-thickness flap 8 mm apical to the MGJ Membrane placed over the denuded root surface and the adjacent tissue; trimmed & adapted to root surface to cover at least 2mm of marginal periosteum. suture passed through the portion of membrane; knotted on the exterior; Non-resorbable Ti-reinforced; (Tinti & Vincenzi) Resorbable
  76. 76. Flap is then positioned coronally & sutured. 4 weeks later, a small envelope flap is performed, and the membrane is carefully removed. The flap is then again positioned coronally, to protect the growing tissue, & sutured. One week later these sutures are removed
  77. 77. GTR technique better when the recession is > 4.98 mm apicocoronally. Coronally displaced flap Vs GTR technique by Pini Prato
  78. 78. Reported:- • 3.66 mm of new connective tissue attachment • 2.48 mm of new cementum and • 1.84 mm of bone growth
  79. 79. Pouch & Tunnel Technique (Coronally Advanced Tunnel Technique) • Effective for the anterior maxillary area ; with adequate vestibular depth and good gingival thickness. Outlined by Azzi
  80. 80. Patient preparation: Plaque control instruction; SRP before the surgical procedure. Composite material stops are placed at the contact points (temporary) to prevent the collapse of the suspended sutures into the interproximal spaces before the surgery On the buccal aspect, sulcular incisions are made around the necks of the teeth using15c & 12D blades; extended to 1 adjacent tooth both mesially & distally .
  81. 81. Small, contoured blades & mini curettes are used to create the recipient pouches and tunnels. Dissect the connective tissue beyond the mucogingival line and free the buccal flap from its insertions to the bone around each tooth. Muscle fibers, any remaining collagen fibers are cut & papillae carefully undermined to allow the coronal positioning of entire gingivopapillary complex. Papillae are kept intact
  82. 82. Size of the pouch (including the area of the denuded root surface, is measured so that an equivalent size donor connective tissue can be procured from the tuberosity. Connective tissue harvested from the tuberosity area is contoured to fit into the recipient tunnel & pouch. mattress suture placed at one end of the graft is helpful in guiding the graft
  83. 83. • Tissue is gently pushed into pouch & tunnel with tissue forceps & packing instrument. Mattress suture will help maintain the graft in position
  84. 84. The entire gingivopapillary complex (buccal gingiva with the underlying connective tissue graft, and papillae) is coronally positioned using a horizontal mattress suture anchored at the incisal edge of the contact area. The contact areas are splinted presurgically using a composite material. • Vertical mattress suture: To hold the graft in position beneath the gingiva.
  85. 85. • Minimize incisions & the reflection of flap. • Provides abundant blood supply to the donor tissue, • Placement of donor connective tissue into pouches beneath papillary tunnels allows for intimate contact of donor tissue to the recipient site. • The positioning of the graft in the pouch and through the tunnel and the coronal placement of the recessed gingival margins completely covers the donor tissue. • Excellent esthetic result • Thickening of the gingival margin after healing:- stable to allow for the possibility of “creeping reattachment” of the margin ADVANTAG ES
  86. 86. • Requires 2 surgical sites; • Delicate harvesting of graft; • Prolonged healing time. DISADVANTAG ES
  87. 87. VISTA Technique Vestibular Incision Subperiosteal Tunnel Access
  88. 88. Pin hole surgical technique: John C. Chao  Using PST, mean % defect coverage was 94%.
  89. 89. CONCLUSION New techniques are constantly being developed and are slowly being incorporated into periodontal practice. Critical analysis of newly presented techniques should guide our constant evolution toward better clinical methods.
  90. 90. BIBLIOGRAPHY…..  Newman, Takei, Fermin A Carranza. Clinical periodontology, 12th Edition.  Jan Lindhe. Clinical Periodontology and Implant Dentistry, 5th Edition • Serge Dibart , Mamdouh Karima. Practical Periodontal Plastic Surgery. • Francisco J Otero-Cagide , M. Fermín Otero-Cagide : Unique Creeping Attachment after Autogenous Gingival Grafting: Case Report. J Can Dent Assoc 2003; 69(7):432–5 • Informational Paper: Oral Reconstructive and Corrective Considerations in Periodontal Therapy; J Periodontol 2005;76:1588-1600.
  91. 91. • Pini Prato GP, Tinti C, Vincenzi G, Magnani C, Cortellini , Clauser C. Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal recession. J Periodontol 1992;63:919-928. • Cortellini P. , Clauser C. , Pini Prato GP. Histologic assessment of new attachment following the treatment of a human buccal recession by means of a guided tissue regeneration procedure. J Periodontol 1993;64:387-391. • Cohen W, Ross SE. The Double Papillae Repositioned Flap in Periodontal Therapy. J Periodontol 1968;39:65-70. • Nelson SW. The subepithelial connective graft: A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102.
  92. 92. • Kumar PM, Reddy NR, Kumar SS, Chakrapani S. Double papilla flap technique for dual purpose. J Orofac Sci 2012;4:75-8. • Harris RJ. Double pedicle flappredictabilityand aesthetics using connective tissue. Periodont s2000, Vol.11,1996,3948 • Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-720. • Carranza FA, Jr, Carraro JJ: Mucogingival techniques in periodontal surgery. J Periodontol 41:294, 1970. • Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva. Journal of Clinical Periodontology. 1974: 1: 185- 196
  93. 93. • Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva. J Clin Periodontol. 1974;1:185–96. • Chao JC. A novel approach to root coverage: The pinhole surgical technique. International Journal of Periodontics and Restorative Dentistry. 2012 Oct 1;32(5):521. • Tarnow, D.P. (1986) Semilunar coronally repositioned flap. Journal of Clinical Periodontology 13, 182–185 • Bernimoulin, Luscher B. , Muhlemann HR. Coronally repositioned periodontal flap: Clinical evaluation after one year. Journal of Clinical Periodontology: 1975: 2; 1-13.
  • AkshitaChipper

    Sep. 14, 2021
  • anjanasuresh22

    Aug. 4, 2021
  • SushantaPahari

    Jul. 24, 2021
  • nikkirana3

    Jul. 22, 2021
  • AnuRadha256

    Jul. 22, 2021
  • LinaBiswal

    Jul. 21, 2021
  • SarigaManimegalai

    Jul. 21, 2021
  • WahidaRahman2

    Jul. 7, 2021
  • DalliSimha

    Jul. 6, 2021
  • RitikaAKapoor

    Jun. 23, 2021
  • PRIYAKAUSHAL5

    Jun. 23, 2021
  • shikhasingh417

    Jun. 21, 2021
  • ssuserdc94dd

    Jun. 14, 2021
  • UrmiAgrawal1

    Jun. 8, 2021
  • ShrutiShetty53

    Jun. 5, 2021
  • AliaSafadi

    May. 26, 2021
  • shivktanshahakar

    May. 25, 2021
  • amishbansal

    May. 19, 2021
  • SantoshVamsi1

    May. 3, 2021
  • niyageorge2

    Apr. 28, 2021

Periodontal plastic surgery-1 PRESENTER DR. REBICCA RANJIT IIIrd YEAR RESIDENT

Vistas

Total de vistas

20.390

En Slideshare

0

De embebidos

0

Número de embebidos

13

Acciones

Descargas

0

Compartidos

0

Comentarios

0

Me gusta

231

×