Mucogingival surgeries other than soft tissue grafts

• Mucogingival surgery - Periodontal surgical procedures designed to correct defects in the morphology, position and/or amount of gingiva surrounding teeth (AAP,1992)

RATIONALE

Increasing the dimensions of the gingival tissues to stop or prevent recession

Facilitate plaque control

Reduce or eliminate root sensitivity

Improve aesthetics

The original concept of mucogingival surgery addressed only three problems:

A shallow vestibule, The aberrant frenum andProblems associated with attached gingiva.

PERIODONTAL PLASTIC SURGERY

Periodontal plastic surgery, encompasses a much broader range of treatment.

Periodontal plastic surgery - includes ‘‘mucogingival surgery’’, since it addresses the treatment of all deformities in the gingival or alveolar mucosa, but it also applies to modifications in the edentulous ridge size and shape as well as surgical procedures for improvement of soft tissue esthetics. (Miller PD, 1998)

INCREASING THE WIDTH OF ATTACHED

GINGIVA

• SHALLOW VESTIBULE

• ABERRANT FRENUM

ESTHETIC• ESTHETIC SMILE

SURGICAL EXPOSURE

• IMPACTED TEETH• CORTICOTOMY ASSISTED

ORTHODONTIC TREATMENT

RIDGE COLLAPSE

• RIDGE AUGMENTATION• GRAFTING EXTRACTION SITES

• INTERDENTAL PAPILLARY RECONSTRUCTION

• CORRECTION OF AESTHETIC DEFECTS AROUNS THE IMPLANTS

INCREASING THE WIDTH OF ATTACHED GINGIVA

• The attached gingiva is defined as the tissue between the mucogingival junction and the projection on the external gingival surface of the most apical portion of the gingival sulcus or the periodontal pocket.

What is adequate attached gingiva?CONTROVERSIAL

With proper oral hygiene and absence of bacterial plaque, gingival health ,in the form of no attachment loss and absence of inflammation can exist in areas where minimal or no attached gingiva is present. (Miyasato et al, 1977)

Minimum width of 2 mm of gingiva needs to be present for gingival health to exist. (Lang & Löe ,1992)

Wennstrom study (1987) Lack of minimally attached gingiva does not necessarily result in development of soft tissue recession

Lindhe and Nyman (1980) In the presence of proper plaque control measures, the apico-coronal width of gingiva and the presence or absence of an attached portion of gingiva are not of decisive significance for the maintenance of the periodontal tissues

Dorfman et al. (1980) Confirms that areas with minimal attached gingiva will not have further attachment loss if inflammation is controlled

• Width of attached gingiva or lack there of should not solely determine a pathological diagnosis.

• Commonly agreed that areas with less than 2 mm of attached gingiva are at a higher risk for recession.

Tension test to establish whether the gingival and oral mucosa complex is adequate for the maintenance of gingival health

Indications to augment attached gingiva

Patient experiences discomfort during tooth brushing and/or chewing due to interfering lining mucosa.

Patients planned for orthodontic or restorative procedures

Patients with active sites of recession

If crowns, bridges, RPI partials or over dentures are planned involving the concerned tooth.

Increase in gingival thickness rather than in apico-coronal dimension

When < 1mm of attached gingiva is present and

TREATMENT MODALITIES• Denudation technique• Periosteal retention• Vestibular extension procedure• Apically displaced flap• Free gingival grafts

Denudation technique

Removal of all soft tissue within an area extending from the gingival margin to a level apical to the mucogingival junction leaving the alveolar bone completely exposed(Ochsenbein ,1960; Corn,1962;Wildermann,1964)

Limited effect in height of the gingival zone

• Severe bone resorption with permanent loss of bone height

• Severe post-operative pain• Recession of marginal gingiva exceeded gain of

gingiva in the apical portion of the wound

Periosteal retention/ split flap procedure

• Only superficial portion of the oral mucosa within the wound area was removed leaving the bone covered by periosteum (Staffileno et al. (1962), Wildermann (1963), Pfeifer (1965)

• Less bone resorption as compared to denudation technique

• However, crestal bone resorption was inevitable unless relatively thick layer of connective tissue was retained on bone

HEALING FOLLOWING VETIBULAR EXTENSION PROCEDURES

Apically displaced flap

• The apically displaced flap technique can be used for

(1)pocket eradication and/or(2)widening the zone of attached gingiva.(3)crown lengthening procedures for cosmetic enhancement and restorative treatment

Friedman and Levin Classification ,1962

• Class I: More than adequate keratinized gingiva widthLabial or buccal incision 1-3mm from crest of gingiva.Flap apically positioned to cover 1-2mm of cementum

• Class II: Adequate keratinized gingivaCrestal incision used.Flap apically positioned to the crest of the bone

• Class III- Insufficient gingival keratinized width

Sulcular incisionFlap is positioned 1-2mm below crest of bone to increase width of keratinized gingiva.

VESTIBULOPLASTY

• Inadequate vestibular depth- Lack of adequate vestibular depth is another adverse anatomic situation often observed in areas with mucogingival problems.

Upper canine presents with the cheek mucosa attached to its gingival line.

Tension test will demonstrate the gingival tissue inadequacies in these regions.

• Vestibuloplasty or sulcoplasty or sulcus deepening procedure

Deepening of the vestibule without any addition of bone.

• Goals of the surgery: To increase

The size of the denture bearing area,Height of residual alveolar ridgeFacilitation of plaque control

• Mucosal advancement vestibuloplasty • Submucosal vestibuloplasty

Obwegeser’s technique

• Secondary epithelization vestibuloplastyKazanjian technique

Obwegeser’s technique

• Grafting vestibuloplasty Mucosal graft

Skin graft

Kazanjian technique (1924)

• Eliminates the sharp V in the depth of the extended vestibule and counteracts shallowing of the sulcus.

• Enables denture fabrication with better flange extension and improved oral hygiene.

• INDICATED – adequate bone remaining for denture support, but the overlying mucosa is quantitatively deficient or diseased hyperplasia or scarring.”

• Kazanjian and most of its modifications scar contracture loss of vestibular depth.

• “ Liposky” described the process-

Fibrous band that forms at the junction of the graft or flap and the existing tissues

Fibrous band is thick and contracts during the early maturation process (1 to 3 months)

Loss of vestibular depth

Therefore, attention has been directed toward an overcorrection or overextension and proper fixation of the flap or graft.

Clarke’s technique

• Instead of flap being pedicled off the alveolar bone it is pedicled off the labial mucosa

• Horizontal incision is performed from canine to canine between immobile gingiva and mobile gingiva

• Supraperiosteal dissection

Mucosa is sutured at the depth of the vestibule

Denuded periosteum heals by secondary epithelialization

It is possible to use tissue graft on exposed periosteum. The healing process is more rapid in this situation.

Periosteal fenestrationIncision near MGJReflection of split thickness flapMuscle fibres dissected from periosteum and mucosal flap freed

Strip of exposed periosteum is removed at the level of original MGJ– fenestration exposing the bone

Mucosal flap sutured at depth of vestibule Maintained by scar tissue formed at area of fenestration

Edlan- mejchar technique

2 vertical incision from gingival margin into alveolar mucosa Horizontal incision 10-12 mm from

alveolar margin

Mucosal flap elevated leaving periosteum on bone

Periosteum separated from bone, with muscle attachments and it is transposed to lip

Mucosal flap folded down over bone and sutured to inner aspect of periosteum

Transposed periosteum sutured to initial horizontal incision on lip

• Secondary wound at donor site for a free graft is not required

• Creates mainly attached mucosa

• Difficulty in lip dissection

• Damage to the innervation in the area

ADVANTAGES DISADVANTAGES

Complications of vestibuloplasty

1. Pain and oedema,2. Transient paraesthesia,3. Hypersensitivity of the surgical site4. Breakdown of the sutured margin of the

mucosa,5. Damage to the mucosal flap, 6. Sagging chin,7. Infection.

FRENECTOMY

• The word frenum is derived from the Latin word “fraenum”.

• Frena, are triangle-shaped folds found in the maxillary and mandibular alveolar mucosa, and are located between the central incisors and canine premolar area.

• Frenum may be classified depending upon its morphology as:

Long and thin

Short and broad.

MucosalGingival

PapillaryPapillary penetrating.

Depending upon the attachment level, frenum has been classified as: (Placek et al. 1974)

• Aberrant frenum can be treated by frenectomy or frenotomy procedures.

Frenectomy is a complete removal of the frenum, including its attachment to the underlying bone, and may be required for correction of abnormal diastema between maxillary central incisors (Friedman 1957).

Frenotomy is the incision and relocation of the frenal attachment.

• Tension on the gingival margin (frenal-pull concomitant with or without gingival recession)

• Facilitate orthodontic treatment• Facilitate home care.

Conventional techniqueUsing soft tissue lasers.

INDICATIONS

TECHNIQUES

Conventional technique

• Different procedures have been mentioned under the conventional frenectomy technique.

Dieffenbach- VplastySchuchardt, & Mathis- Z plasty

Armamentarium• Bard-Parker handles no. 3, • No. 15 blade, mosquito haemostat, suture material.

Classical frenectomy• The classical technique was introduced by Archer (1961) and

Kruger (1964).

• This approach was advocated in the midline diastema cases with an aberrant frenum to ensure the removal of the muscle fibers which were supposedly connecting the orbicularis oris with the palatine papilla .

• This technique is an excision type frenectomy which includes the interdental tissues and the palatine papilla along with the frenulum.

The frenum is engaged with a haemostat which was inserted into the depth of the vestibule

Incisions are placed on the upper and the undersurface of the haemostat until the haemostat was free

The edges of the diamond shaped wound were sutured by using 4-0 black silk with interrupted sutures

The triangular resected portion of the frenum with the haemostat was removed. A blunt dissection was done on the bone to relieve the fibrous attachment.

Miller s technique (1985)

This technique was proposed for the post-orthodontic diastema cases.

The ideal time for performing this surgery is after the orthodontic movement is complete and about 6 weeks before the appliances are removed.

Allows healing and tissue maturation, permits the surgeon to use orthodontic appliances as a means of retaining a periodontal dressing.

V-Y plasty

INDICATIONS

Lengthening the localized area, like the broad frena in the premolar-molar area.

Employed in a case of a papilla type of frenal attachment

Pre-operative papilla type of frenal attachment

Frenum held with hemostat

Frenum incised by V-shaped incision

V-shaped incision sutured in the form of Y

Z plasty

Indications• Hypertrophy of the frenum with a low

insertion, which is associated with an inter-incisor diastema,

• Lateral incisors have appeared without causing the diastema to disappear

• Cases of a short vestibule.

The main advantage of this method over the Vplasty method was minimal scar tissue formation.

Flaps transposed across the midline sutured in the form of Z

Incision given at both ends of the frenum to obtain 2 triangular flaps

Incision given through the frenum

Pre-operative attached type of frenal attachment

Electrosurgery

INDICATIONS• Patients with bleeding disorders, • Non-compliant patients.

Armamentarium: An electrocautery unit with the loop electrode and a haemostat.

Lasers• Carbon dioxide laser• Neodymium:YAG laser• Erbium:YAG laser• Diode lasers• Excimer laser• Argon laser

Lingual frenectomy• GA/LA• Traction suture through tongue tip for elevation to

tense the frenum

• 1st method: cutting of frenal attachment to alveolar ridge, small wound closed with interrupted sutures

• 2nd method : transverse incision halfway between ventral aspect of tongue and sub-mandibular duct caruncles (sectioning of fibres posterior to duct openings rather than near alveolar ridge)

• 3rd method : to prevent involvement of structures in floor of mouth, appx. 2mm of attachment is separated from mucosa at weekly intervals

Elevation of tongue by suture through the tip

Excision by converging incisions to the base

Undermining edges with scissors

suturing

Crown lengthening• Crown lengthening aims to increase

the clinical crown length of a tooth or teeth for either esthetic or restorative purposes or a combination of both.

Esthetic smile• In an esthetic smile, the edges of the

maxillary anterior teeth follow a convex or gull-wing course matching the curvature of the lower lip

75%–100% of the maxillary anterior teeth and the interproximal gingiva Central incisors & canines at the same level Laterals 2 mm below The maxillary incisal curve is parallel with the lower lip

The position of the anterior contact point progressing from incisal to cervical and from central incisors to canines.

The gingival zenith is distal on the maxillary central incisors and canines, coincidental on lateral incisors.The golden percentage (25%, 15%, and 10%)

Diagnosis• The height of the anatomic crown is measured from

the cementoenamel junction to the incisal edge, while the height of the clinical crown is measured from the gingival margin to the incisal edge.

• A comparison of these two measurements will determine whether short clinical crowns are a result of incisal wear or a coronal position of the gingival margin.

• Coronal position of the gingival margin with respect to the cementoenamel junction may be the result of delayed passive eruption or of gingival enlargement.

• Excessive gingival display (known as a gummy smile), altered passive eruption (in which the alveolar crest is 2 mm from the cemento-enamel junction

• Lack of tooth structure, or access for restorative purposes (requiring the removal of soft or hard tissue or a combination of both) and the adjacent periodontium of neighboring teeth.

SOFT TISSUE CROWN LENGTHENING

HARD TISSUE CROWN LENGTHENING

GUMMY SMILE

• Ideally, the smile should expose minimal gingiva, the gingival contour should be symmetric and in harmony with the upper lip, the anterior and posterior segments should be in harmony, and the teeth should be of normal length.

• Gummy smile attributed to:Tooth malpositioning( shallow probing depth<4mm)

Altered passive eruption( deep probing depth>4mm)

Vertical maxillary excess( > 8mm of gingival display)

• Garber and Salama (1996) classifications for excessive gingival display and their proposed treatments.

• Degree I had 2 to 4 mm of gingival display, and treatment would be orthodontic intrusion alone, orthodontics and crown lengthening or crown lengthening followed by restorations.

Degree II had 4 to 8 mm of gingival display, and treatment would be crown lengthening and restorations or orthognathic surgery depending on the crown/root ratio.

Degree III had ‡8 mm of gingival display, and treatment would be orthognathic surgery with or without crown lengthening and restorative treatment.

ALTERED PASSIVE ERUPTION

• Failure of the tissue to adequately recede to a level apical to the cervical convexity of the crown.( Goldman and Cohen,1968)

• Altered passive eruption has been classified by Coslet et al,1977 as :

Gingival - anatomic crown relationship:TypeI: gingival margin incisal to CEJ, where there is a noticeable wider gingival dimension from the margin to mucogingival junction Type II: dimension from the gingval margin to the mucogingival junction which appears to be within the normal mean width

• Alveolar crest –CEJ relationshipSubtype A: the alveolar crest- CEJ distance is approximately 1.5 mm. This allows for normal attachment of gingival fibers into cementum

Subtype B: the alveolar crest is at the level of the CEJ.

Treatment of altered passive eruption

• The width and thickness of keratinized gingiva must be measured as well as probing depths, clinical attachment levels and the level of the alveolar crest with respect to the cementoenamel junction.

The procedure is based on two principles: biologic width (BW) establishment and maintenance of adequate keratinized gingiva (KG) around the tooth.

• BIOLOGICAL WIDTHThe BW is defined as the dimension of soft tissue that is attached to the portion of the tooth coronal to the alveolar bone crest.( Gargiulo et al,1961)A minimum of 3 mm of space between restorative margins and alveolar bone would be adequate for periodontal health, allowing for 2mmof BW space and 1 mm for sulcus depth(Ingber et al.,1977)An adequate width of KG should be maintained around a tooth (‡2 mm) for gingival health whenever possible.

If violated :

Gingival recession

Gingival inflammation

Alveolar bone loss

Periodontal pocket formatIon

FUNCTIONAL ASPECT• Crown lengthening for restorative

reasons include increasing retention and to expose subgingival caries, fracture, or restorative margins by increasing the amount of sound tooth structure above the alveolar crest.

FORCED ERUPTION• Procedure in which a tooth is intentionally

moved in a coronal direction using gentle continuous force to effect changes in the soft tissue and underlying bone’(Imber 1989)

Indications

• Alterations in uneven gingival margins• Correction of vertical bony defects• Vertical ridge augmentation for implants• Facilitates establishment of biological

width

Non surgical crown lengthening

• Esthetically compromised bone• Subgingival decay• Tooth fracture• Endodontic reasons

• Goal:Alteration in soft tissue and underlying boneFacilitate establishment of biologic width

Light continuous forces : 20-30gm with suitable anchorage mesially and distally (Wang and Wang ,1992)

• Contraindication:Cannot be done in cases of unfavourable crown: root and often results in the need for a secondary surgical procedure for establishment of adequate biologic width

Treatment: Orthodontic extrusion + supracrestal fibrotomy(Pontoreiro et al. (1987), Kozlowsky et al,

1988)

Subgingival fracture of tooth

Orthodontics to create biologic width

Osteopathy to establish final gingival margin

SURGICAL EXPOSURE OF IMPACTED TEETH

• The maxillary and mandibular third molars are the most commonly impacted teeth due to their long development time

• The maxillary cuspid is the second most frequently impacted tooth (2%).

Labially impacted( 15%)

Palatally impacted(85%)

LABIAL IMPACTION

• Ectopic migration of the canine crown over the root of the lateral incisor or shifting of the maxillary dental midline.

Techniques for uncovering a labially impacted maxillary canine:

• Basic technique- Open eruption( WINDOW TECHNIQUE)

Two lateral releasing incisions are made and extended apically beyond the MGJ

Intrasulcular incision and a partial thickness flap is elevated beyond the ectopically erupting tooth

Mobilized gingival flap is moved apical to the erupting tooth and secured in position by sutures

Excisional uncovering

3 TECHNIQUES MOST COMMONLY USED FOR UNCOEVRING THE CROWN

Apically positioned flap

CLOSED ERUPTION TECHNIQUE

Flap raised with vertical incisons

Attachment is bonded onto the tooth

Traction appliedFull eruption of tooth

4 CRITERIA TO DETERMINE METHOD FOR UNCOVERING THE TOOTH

• I st criteria-assess the labiolingual position of impacted crown

Impacted labially- any of the 3 techniques could be used, little if any bone covering the crown of the impactedcanine.

Impacted in the center of the alveolus- an excisional approach and an apically positioned flap are generally more difficult to perform. Extensive bone might need to be removed from the labial surface of the crown.

• Iind- criterion to evaluate is the vertical position of the tooth relative to the mucogingival junction.

canine crown is positioned coronal to the mucogingival junction

any of the 3 techniques can be used to uncover the tooth.

• canine crown were positioned apical to the mucogingival junction

An excisional technique would be inappropriate, because it would not result in any gingiva over the labial surface of the tooth after it had erupted- APF

• crown were positioned significantly apical to the mucogingival junction

• an APF- result in instability of the crown and possible reintrusion of the tooth after orthodontic treatment -a closed eruption technique - adequate gingiva over the crown and no reintrusion of the tooth in the long term

• IIIrd criterion - evaluate is the amount of gingiva in the area of the impacted canine.

Insufficient gingiva in the area of the canine the- only technique that predictably would produce more gingiva is an apically positioned flap.

Sufficient gingiva to provide at least 2 to 3 mm of attached gingiva over the canine crown after it had been erupted, any of the 3 techniques could be used.

• IV criterion - evaluate is the mesiodistal position of the canine crown.

If the crown were positioned mesially and over the root of the lateral incisor

Difficult to move the tooth through the alveolus unless it was completely exposed with an apically positioned flap. In this latter situation, closed eruption or excisional uncovering generally would not be recommended.

PALATAL IMPACTION

Classified based on 2 variables • The transverse relation of the crown of

impacted tooth to the line of the dental arch

• The height of the crown of the tooth in relation to the occlusal plane

Treatment approach• Closed flap technique• Trap door open technique

Closed flap technique

Flap raised from premolar to midline

Thin shell of bone around the impacted tooth removed with curette/ bur

Follicle removed

Tooth gently luxated

Field is bracketed/ returned to its original position

Flap is completely closed and chain placed through incision line

Trap door technique• Similar to closed flap technique• Area of impacted canine fenestrated

with a bur to create a window (trap door) to expose the bracket through the flap.

• Flap is sutured and chain / wire attached from the bracket/ eyelet to the arch outside the flap.

:COMPLICATIONS

• Injury- Hemorrhage• Fracture of roots and displacement into the

maxillary sinus• Necrosis of the flap due to improper placement.• Fracture of large segment of bone • Traumatization or dislodgement of adjacent teeth

Injury to the soft tissues from the instruments• Forcing a tooth into the maxillary sinus• Opening into the nasal cavity- oro-nasal

communication.• Extensive exposure of the roots of the adjacent

teeth • Discoloration of the soft tissue due to ecchymosis

CORTICOTOMY ASSISTED ORTHODONTIC TREATMENT

• 1892- defined as a linear cutting technique in the cortical plates surrounding the teeth to produce mobilization of the teeth for immediate movement

• Direct correlation between the severity of bone corticotomy and/or osteotomy and the intensity of the healing response, leading to accelerated bone turnover at the surgical site. This was designated “Regional Acceleratory Phenomenon” (RAP).

( Frost,1981)

Wilcko,2009)

WILCKO (2009)---Accelerated Osteogenic Orthodontics (AOO) [or Periodontally Accelerated Osteogenic Orthodontics (PAOO)

• This technique is similar to conventional corticotomy except that selective decortication in the form of lines and points is performed over all of the teeth that are to be moved.

• In addition, a resorbable bone graft is placed over the surgical sites to augment the confining bone during tooth movement.

CONCLUSION

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