PERIODONTAL PLASTIC AND

ESTHETIC SURGERYJOSNA THANKACHAN

FINAL YEAR PART 1AL-AZHAR DENTAL COLLEGE

INTRODUCTION Periodontal plastic surgery - the term initially proposed by miller in 1993 and broadened to include the following areas:-

Periodontal prosthetic correctionsCrown lengtheningRidge augmentationEsthetic surgical correctionsCoverage of the denuded root surfaceReconstruction of the papillaeEsthetic surgical correction around implantsSurgical exposure of unerupted teeth for orthodontics

Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa. Periodontal plastic surgery include only the surgical procedure of mucogingival therapy.

Periodontal plastic surgical procedures include widening of attached gingiva,deepening of shallow vestibules, and resection of aberrant frena,periodontal prosthetic surgery,esthetic surgery around implants and surgical exposure of teeth for orthodontic therapy.

Mucogingival therapy is a broader term that includes non surgical procedures such as papilla reconstruction by means of orthodontic or restorative therapy

CRITERIA FOR SELECTION OF MUCOGINGIVAL TECHNIQUE

1. Surgical site free of calculus, plaque and inflammation -enable the clinician to manage gingival tissue that is firm ,meticulous precise incision and flap reflection cannot be achieved when gingival tissue edematous.

2. Adequate blood supply to donor tissue

3. Anatomy of recipient and donor tissue

4. Minimal trauma to surgical site

5. Stability of the grafted tissue to the recipient site.

The three objectives of periodontal plastic surgery, Problem associated attached

gingiva with shallow

vestibule

aberrant frenum

PROBLEM ASSOCIATED WITH ATTACHED GINGIVA

The original rationale for muco gingival surgery predicted on the assumption that a minimal width of attached gingiva was required to maintain optimal gingival health.

A wide attached gingiva is more protective against the accumulation of plaque than a narrow or a non existent zone.

Persons who practice excellent oral hygiene may maintain healthy areas with almost no attached gingiva.

Recession of anterior maxillary tooth cause an esthetic defect in individual with high smile line.

The coverage of denuded root for esthetic purposes also widens the zone of attached gingiva.

Wider zone of attached gingiva around the teeth serve as the abutment for fixed or removable partial denture.

Teeth with subgingival restorations and narrow zone of keratinized gingiva have higher gingival inflammation scores than teeth with similar restorations and wide zone of attached gingiva.

Widening of attached gingiva accomplishes the following three objectives: Enhances plaque removal around the gingival

margin Improves esthetics Reduces inflammation around restored teeth

PROBLEMS ASSOCIATED WITH SHALLOW VESTIBULE.Proper oral hygiene measures are jeopardized.Sulcular brushing technique requires placement of

toothbrush at the gingival margin, which may not be possible with shallow vestibule

Minimal attached gingiva with adequate vestibular depth may not require surgical correction if proper atraumatic hygiene is practiced with a soft brush.

Minimal amounts of keratinized attached gingiva with no vestibular depth usually benefit from mucogingival correction.Proper placement of removable prosthesis may not be possible without adequate vestibular depth.

PROBLEMS ASSOCIATED WITH ABERRANT FRENUMA frenum that encroaches on the margin of

the gingiva may interfere with plaque removal, and tension on this frenum may tend to open the sulcus. In this case, surgical removal of frenum is indicated.

TECHNIQUES TO INCREASE ATTACHED GINGIVA

GINGIVAL AUGMENTATION APICAL TO RECESSION

GINGIVAL AUGMENTATION CORONAL

TO THE RECESSION (root coverage)

GINGIVAL AUGMENTATION APICAL TO THE RECESSION

A graft ,either pedicle or free, is placed on a recipient bed apical to recessed gingival margin. No attempt is made to cover the denuded root surface.

TECHNIQUES

Free gingival autograft Free connective tissue autograft Apically positioned flap

FREE GINGIVAL AUTOGRAFT Free gingival graft are used to create a widened

zone of attached gingiva.Initially described by bjorn in 1963THE CLASSIC TECHNIQUE

STEP 1: PREPARE THE RECIPIENT SITE The purpose of this step is to prepare firm connective tissue bed to receive the graft .The recipient site can be prepared by incising at existing mucogingival junction with a #15 blade to the desired depth. Periosteum should be left covering the bone.

recipient site

prepared for free gingival graft

Before treatment

Extend the incisions to approximately twice the desired width of the attached gingiva ,allowing for 50% contraction of the graft when healing is complete.

The amount of contraction depend on the extent to which the recipient site penetrates the muscle attachments. The deeper the recipient site, greater is the tendency for the muscles to elevate the graft and reduce the final width of the attached gingiva.

Insert a #15 blade along the cut gingival margin and separate a flap consisting of epithelium and underlying connective tissue without disturbing the periosteum.

Extend the flap to the depth of the vertical incisions.

If a narrow band of attached gingiva remains after pockets are eliminated ,it should be left intact,and the recipient site should be started by inserting the blade at the mucogingival junction instead of at the cut gingival margin.

Suture the flap where the apical portion of the free graft will be located. Three to four independent gut sutures are placed. The needle is first passed as a superficial mattress suture perpendicular to the incision and then on the periosteum parallel to the incision.

Make an aluminum foil template of the recipient site to be used as a pattern for the graft.

Graft can also be placed directly on the bone tissue , for this technique flap should be separated with a blunt dissection with a periosteal elevator.

ADVANTAGE Less swelling Better haemostasis Less shrinkage Less post operative mobility

STEP 2; OBTAIN A GRAFT FROM DONOR SITE

Transferring a piece of keratinized gingiva approximately the size of the recipient site.

Palate is the usual site from which donor tissue is removed

The graft should consist of an epithelium and a layer of connective tissue.

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 and hold it with tissue forceps.

Template placed

Graft procured

FREE GRAFT

Proper thickness is important for survival of graft. it should be thin enough to permit ready diffusion of nutritive fluid from the recipient site .

A graft that is too thin may necrosis and expose the recipient site.

if it is too thick its peripheral layer is jeopardized because of the excessive tissue that separate it from new circulation and nutrients.

Thick graft also create a deeper wound on donor site with possibility of injuring major palatal arteries, the ideal thickness of graft is between1 and 1.5 mm.

After the graft is separated remove loose tissue tags from the under surface. Thin the edges to avoid bulbous marginal and interdental contours.

STEP 3: TRANSFER AND IMMOBILIZE THE GRAFT Remove the sponge from the recipient site; reapply it, with pressure if necessary, until bleeding is stopped. Remove the excess clot. A thick clot interferes with vascularization of 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. The graft must be immobilized, any movement interfere with healing.

Graft transferred to recipient site

Avoid excessive tension which can distort the graft from the underlining surface.

STEP 4: PROTECT THE DONOR SITE. Cover the donor site with a periodontal pack for one week. If facial attached gingiva was used , the pack may be retained by locking it through the inter proximal spaces on to the lingual surface . If there are no open interdental spaces ,the pack can be covered by a plastic stent wired to the teeth.A modified Hawley retainer is useful to cover the pack on the palate and over edentulous ridges.

VARIANT TECHNIQUESVariant techniques attempt to minimize the donor

site wound by removing the donor tissue in a different configuration and altering the shape to maximize coverage over the recipient site.

These techniques are:-1) The accordion technique2) The strip technique3) The combination epithelial – connective tissue strip

techniqueAll are modifications of the free gingival grafts.

THE ACCORDION TECHNIQUE Described by Rateitschak et al Attains expansion of graft by alternate

incisions in opposite sides of the graft. This technique increases the donor

graft tissue by changing the configuration of the tissue

STRIP TECHNIQUE Developed by Han et al Consists of obtaining 2 or 3 strips of gingival

donor tissue about 3-5mm 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.

Mucosal tissue around implants

Recipient site prepared

Donor site with strips of free graft removed Donor strips of free graft

Strips placed side by side on recipient site

Healing of the recipient site after 3 months

The advantages of this technique are:- Rapid healing of the donor site. The epithelial migration of the close wound

edges (3-5mm) allows rapid epithelialization of the open wound.

The donor site usually does not require suturing and heals uneventfully in 1-2 weeks.

COMBINATION TECHNIQUE A deep strip graft is taken from the palate

and is split into both an epithelial-connective tissue strip and a pure connective strip.

The tissue is obtained as follows:-1. Remove a strip of tissue from the palate about

3 to 4 mm thick2. Place it between two wet tongue depressors3. Split it longitudinally with a sharp #15 blade.

Both will be used as free grafts.

The superficial portion consists of epithelium and connective tissue

Deeper portion consists of only connective tissue

These donor tissues are placed on the recipient site as in the strip technique.

Advantage : minimal donor site wound obtained by two donor tissues from one site.

Alternative donor tissue: Use of palate as a donor site for gingival

augmentation has numerous disadvantages. Patients are fearful of palatal surgery Limitation on the amount of tissue that can be removed.

Currently used substitute for palatal donor tissue: Acellular dermal matrix(ADM) Commercial name: alloderm Derived from donated human skin. Other techniques to avoid palatal donor site

morbidity involve biologic mediators.

HEALING OF THE GRAFT The success of the graft depend on the survival

of the connective tissue. Fibrous organisation of the interface between the graft and the recipient bed occurs within 2 to several days.

The graft is initially maintained by diffusion of fluid from the host bed, adjacent gingiva, and alveolar mucosa. The fluid provide nutrition and hydration essential for the initial survival of transplanted tissues.

During the first day , the connective tissue becomes edematous and disorganized and undergoes degeneration and lysis of some of its elements.

As healing progresses,the edema is resolved,and degenerated connective tissue is replaced by new granulation tissue.

Revascularisation of the graft starts by the second or third day.

Many of the graft vessels degenerate and are replaced by new ones,and some of these participate in the new circulation. The central section of the surface is the last to vascularize,but this is complete by the 10th day.

The epithelium undergoes degeneration and sloughing,with complete necrosis occuring in some areas. It is replaced by new epithelium from the borders of the recipient site.

A thin layer of new epithelium is present by the fourth day,with retepegs developing by the 7th day.

Healing of the graft of intermediate thickness (0.75mm) is complete by 10.5 weeks, thicker grafts(1.75mm) may require 16 weeks or longer.

Functional integration of the graft occurs by 17th day but the graft is morphologically distinguishable from the surrounding tissue for months.

FREE CONNECTIVE TISSUE AUTOGRAFT

It is based on the fact that the connective tissue carries the genetic message for the overlying epithelium to become keratinized. Therefore connective tissue from keratinized zone can be used as graft.

The advantage of this technique is that the donor tissue is obtained from the under surface of the palate flap which is sutured back in primary closure, there for healing is by first intention. The patient has less discomfort post operatively at the donor site.

Better esthetics can be achieved because of a better colour match of the grafted tissue to adjacent areas.

A) Lack of keratinized attached gingiva buccal to cenral incisor; B)vertical incisions to prepare recipient site

C) recipient site prepared E) removal of connective tissue

donor site sutured connective tissue for graft

connective tissue placed at donor site

final healing at 3 months Better esthetics can be achieved because of a better colour match of the grafted tissue to adjacent areas.

APICALLY DISPLACED FLAP This technique uses the apically positioned flap

either partial thickness or full thickness, to increase the zone of keratinized gingiva.

This technique increase the width of the keratinized gingiva but cannot predictability deepen the vestibule with attached gingiva

Adequate vestibular depth must be present before the surgery to allow apical positioning of the flap.

Accomplishments : The apically displaced flap technique

increases the width of the keratinized gingiva but cannot predictability deepen the vestibule with attached gingiva.

Adequate vestibular depth must be present before the surgery to allow apical positioning of the flap.

The edge of the flap may be located in 3 positions in relation to the bone:- 1) Slightly coronal to the crest of the

bone 2) At the level of the crest 3) 2mm short of the crestOther techniques : vestibular extension

technique described by Edlan and MejcharProduced significant widening of attached

nonkeratinized tissue.

GINGIVAL AUGMENTATION CORONAL TO RECESSION (ROOT COVERAGE)

Sulivan and Atkins classified gingival recession based on 4 anatomic categories:

1. Shallow – narrow2. Shallow - wide3. Deep - narrow4. Deep - wide

CLASSIFICATION OF GINGIVAL RECESSION BY MILLER

CLASS 1: Marginal tissue recession does not extend to the mucogingival junction. No bone loss or soft tissue in the interdental area.CLASS 2: Marginal tissue recession extends to or beyond the mucogingival junction. . No bone loss or soft tissue in the interdental area.CLASS 3: Marginal tissue recession extends to or beyond the mucogingival junction. Bone and soft tissue loss interdentally or malpositioning of the tooth.CLASS 4: Marginal tissue recession extends to or beyond the mucogingival junction. Severe bone and soft tissue loss interdentally or severe tooth malposition.

P.D. Miller’s classification of denuded roots

A graft is placed covering the denuded root surface. Both apical and coronal widening of attached gingiva enhance oral hygiene procedures.TECHNIQUES USED :-

Free gingival autograft Free connective tissue autograft. Pedicle autograft

Laterally(horizontally) positioned pedicle flap Coronally positioned flap; includes semilunar

pedicle (Tarnow) Subepithelial connective tissue graft Guided tissue regeneration Pouch and tunnel technique.

FREE GINGIVAL AUTOGRAFT The classic technique: Miller applied the classic free gingival

autograft with a few modifications:-STEP 1: Root planing. Root planing is performed with the

application of saturated citric acid for 5 min on the root surface.

STEP 2 : Prepare the recipient site, make a horizontal incision in the interdental papillae at right angles to create a margin against which the graft may have a butt joint with the incision. Vertical incisions are made at proximal line angles of adjacent teeth and the retracted tissue is excised. Maintain an intact periosteum in the apical area.

STEP 3 and 4 : Similar to the classic technique described earlier.

FREE CONNECTIVE TISSUE AUTOGRAFT

STEP1:DIVERGENT VERTICAL INCISION Divergent vertical incision are made .At the line angle of the tooth to be covered, creating a partial thickness flap to atleast 5mm apical to the receded area .

STEP 2: SUTURING Suture the apical mucosal border to the periosteum using a gut suture.

STEP3: SCALING AND ROOT PLANING. Scale and plane the root surface, reducing any prominence of root surface.

STEP 4:OBTAIN THE GRAFT From the palate obtain a connective tissue graft. Donor site is sutured after the graft is removed.

STEP 5: TRANSFER THE GRAFT Transfer the graft to the recipient site, and suture it to the periosteum with the gut suture. Good stability of the graft must be attained with adequate suture.

STEP 6:COVER THE GRAFT Cover the grafted site with aluminium foil and periodontal dressing.

PEDICLE AUTOGRAFT LATERALLY DISPLACED FLAP

The laterally displaced flap can be used to cover isolated ,roots that have adequate donor tissue laterally and vestibular depth.

STEP 1: PREPARE THE RECIPIENT SITE Epithelium is removed around the denuded root surface. The exposed connective tissue will be the recipient site for the laterally displaced flap.

Pre operative view,maxillary bicuspid Recipient site is exposed by preparing

the connective tissue around the recession

STEP 2: PREPARE THE FLAP

The periodontium of the donor site should have a satisfactory width of attached gingiva and minimal loss of bone without dehiscence or fenestration. A full thickness or partial thickness flap may be used. With a #15 blade make a vertical incision from the gingival margin to outline a flap adjacent to the recipient site. Incise to the periosteum and extend the incision into the oral mucosa to the base of the recipient site .The flap should be sufficiently wider than the recipient site to cover the root and provide a broad margin for attachment to the connective tissue border around the tooth.

Incisions are made at the donor site in preparation of moving the tissue laterally

STEP 3:TRANSFER THE FLAP

Slide the flap laterally on to the adjacent root ,making sure that it lies flat and firm without excess tension on the base. Fix the flap on the adjacent gingiva and alveolar mucosa at the distal corner of the flap.

Pedicle flap is sutured in position

STEP 4:PROTECT THE FLAP AND DONOR SITE

Cover the operative field with aluminium foil and a soft periodontal pack extending it interdentally and onto lingual surface to secure. Remove the pack and suture after one week.

Post operative result at 1 year

VARIANT TECHNIQUES:- There are many variations in the incisions for the

laterally displaced flap. Use of converging oblique incisions over the

recipient site and a vertical or oblique incision at the distal end of the donor site so that the transposed flap is slightly wider at its base.

The marginal attachment at the donor site is preserved to reduce the likelihood of recession and marginal bone resorption , but this requires a donor site with wider zone of attached gingiva.

Sliding partial thickness grafts from neighboring edentulous areas (pedicle grafts) can be used to restore attached gingiva on teeth adjacent to edentulous spaces with denuded roots and a small vestibular fornix ,often complicated by tension from a frenum.

“double papilla flap” attempts to cover roots denuded by isolated gingival defects with a flap formed by joining the contiguous halves of the adjacent interdental papillae.

CORONALLY DISPLACED FLAP The purpose of coronally displaced flap procedure is to create a split thickness flap in the area apical to the denuded root and position it coronally to cover the root.

STEP 1: With two vertical incisions ,delineate the flap ,these incisions should go beyond the mucogingival junction. Make a internal bevel incision from the gingival margin to the bottom of the pocket to eliminate the diseased pocket wall.

STEP 2: Scale and plane the root surface.

STEP 3: Return the flap and suture it at a level coronal to the pretreatment procedure. Cover the area with a periodontal pack, which is removed along with the suture after one week.

VARIANTS TO FIRST TECHNIQUE:- Results with the coronally displaced flap

technique are often unfavourable because of insufficient keratinized gingiva apical to the recession.

To overcome this problem and to increase the chances of success ,a gingival augmentation procedure with a free autogenous graft can be performed before the coronally positioned graft.

This creates several millimeters of attached keratinized gingiva apical to the denuded root.

2 months after this surgery,a second ctage procedure is performed,coronally positioning the flap that includes the free autogenous graft.

Use citric acid with a pH 1.0 for conditioning the root surface.

Preoperative viewflap has been raised

The composite resin restoration removedClose suturing of the flap to cover the exposed root surface

Healing outcome 1 year postoperatively

SECOND TECHNIQUE Tarnow has described the semilunar

coronally repositioned flap to cover isolated denuded root surfaces.

STEP 1: A semilunar incision is made following the curvature of the receded gingival margin and ending about 2-3mm short of the tip of the papillae.

STEP 2: Perform a split thickness dissection coronally from the incision and correct it to an intra sulcular incision.

STEP 3: The tissue will collapse coronally covering the denuded flap. It is then held in its new position for a few minutes with a moist gauze. Many cases donot require either sutures or periodontal dressing. This technique is simple and predictably provides 2 to 3mm of root coverage.

This technique is indicated where the recession is not extensive (3mm) and the facial gingival biotype is thick.

Semilunar coronally positioned flap. A. slight recession in facial of the upper left canine B. After thorough scaling and root planing of the area,a semilunar incision is made and the tissue separated from the underlying bone. The flap collapses ,covering the recession.

C. appearance after 7 weeks

SUBEPITHELIAL CONNECTIVE TISSUE GRAFT

Indicated for 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.

STEP 1: Raise the partial thickness flap with a horizontal incision 2mm away from the tip of the papilla and two vertical incision 1-2 mm away from the gingival margin of the adjoining teeth. extend the flap to the mucobuccal fold without perforation

STEP 2 : Thoroughly plane the root, reducing its convexity.

STEP 3: Obtain a connective tissue graft from the palate by means of horizontal incision 5-6 mm from the gingival margin of the molar and premolars. The connective tissue is carefully removed along with all adipose and glandular tissue.

“Trap-door technique for harvest of a free connective tissue graft.

Horizontal incision , perpendicular to the underlying bone surface,is made approximately 3 mm apical to the soft tissue margin.

Mesio-distal extention of the incision is determined by the graft size required,which is 6mm longer than the width of the dehiscence measured at the level of the CEJ. To facilitate removal of the graft,a vertical releasing incision may be made at the mesial termination of the primary incision.An incision is then placed from the line of the first incision and directed apically to perform a split incision of the palatal mucosa.

STEP4: Place the connective tissue on the denuded root. Suture it with resorbable sutures to the periosteum.

STEP5: Cover the graft with the outer portion of partial thickness flap and suture it interdentally. At least half to two third of the connective tissue graft must be covered over the denuded root.

STEP 6: Cover the area with dry foil and surgical pack after 7 days dressing and sutures are removed.

GUIDED TISSUE REGENERATION TECHNIQUE

Pini – Prato et al described a technique based on the principle of guided tissue regeneration.

GTR should result in reconstruction of the attachment apparatus, along with coverage of the denuded root surface.

GTR technique is better when the recession is greater than 4.98mm apico coronally

STEP1 : A full thickness flap is reflected to mucogingival junction, continuing as a partial thickness flap 8mm apical to the mucogingival junction.

STEP 2: A microporous membrane is placed over the denuded root surface and the adjacent tissue.

STEP 3: A suture is passed through the portion of the membrane that will cover the bone. This suture is knotted to the exterior and tied to bend the membrane .Creating a space between root and membrane.

This space allow growth of tissue beneath the membrane.

STEP 4: the flap is then positioned coronally and sutured. Four weeks later a small envelop flap is performed,and the membrane is carefully removed. The flap is then again positioned coronally ,to protect the growing tissue, and sutured . One week later these sutures are removed.

Membranes used are Titanium-reinforced membranes Resorbable membranes GTR technique is better when the

recession is greater than 4.98mm apicocoronally

Coronally advanced flap procedure combined with titanium reinforced non biodegradable membrane barrier

Trapezium shaped full thickness flap is raised beyond the bone dehiscence.

C. Membrane barrier placed and anchored to the tooth by a sling suture placed at the level of CEJ.D. Mobilized flap is positioned coronally and secured by interdentally placed interrupted sutures.Membrane should be completely covered by the flap to reduce the risk of bacterial contamination during healing.

The use of non-biodegradable membrane barriers requires a second surgery for membrane removal,usually after 5-6 weeks.A partial thickness flap is raised to expose the membrane.

The 1 year post operative result.

POUCH AND TUNNEL TECHNIQUE Also referred to as coronally advanced tunnel technique.

To minimize incisions and reflection of flaps and to provide abundant blood supply to the donor tissue ,the placement of sub epithelial donor connective tissue into pouches beneath papillary tunnel allow for intimate contact of donor tissue to the recipient site.

Effective for the anterior maxillary area, where the vestibular depth is adequate and there is good gingival thickness.

Advantage: The thickening of the gingival

margin after healing. The thicker gingival margin is stable to allow for possibility of “creeping attachment” o0f the margin.

The use of small contoured blades enable the surgeon to incise and split the gingival tissues to create the recipient pouches and tunnels.

STEP 1: Using a blade a sulcular incision is made around the teeth adjacent to the recession .This incision separate the junctional epithelium and the connective tissue attachment from the root.

STEP2: Using either a curette or a small blade such as the #15 , a tunnel is created beneath the adjacent buccal papilla into which the connective tissue is placed.

STEP 3: A split thickness pouch is created apical to the papilla ,which has been tunneled ,this pouch may extend 10-12 mm apical recessed gingival margin and papillla and 6-8mm mesial and distal denuded root surface.

STEP 4: The size of the pouch which include area of denuded root surface is measured so that an equivalent size of donor connective tissue can be procured from the palate.

STEP 5: Using suture ,curettes and elevator the connective tissue is placed under the pouch and tunnel with a portion covering denuded root surface.

STEP 6: The mesial and distal end of the donor tissue are secured by gut suture. The gingival margin of the flap is coronally placed and secured by horizontal mattress suture that extend over the contact of two adjacent teeth

STEP 7: Other holding sutures are placed through the overlying gingival tissue and donor tissue to the underlying periosteum to secure and stabilize the donor tissue beneath the gingiva.

STEP 8: A periodontal dressing is used to cover the surgical site.

A. Preoperative viewb. Sulcular incision is made mesial to the line angles

C.A tunnel is made through the papilla using a blunt incision

d. A connective tissue graft is taken from the palate

E. The connective tissue is placed through the papillary tunnel and apically beneath the pouch.

F. The facial gingival margin covers the connective tissue using horizontal mattress sutures interdentally

Post operative view

TECHNIQUES TO DEEPEN VESTIBULE

Another objective of periodontal plastic surgery is the creation of some vestibular depth when this is lacking

Gingival recession displaces the gingival margin apically thus reducing vestibular depth.

Adequate vestibular depth is important for both oral hygiene and retention of prosthetic appliance.

Deepening of vestibule can only accomplished by use of free autogeneous graft.

VESTIBULOPLASTY TECHNIQUES1. Mucosal advancement vestibuloplasty a) Closed submucosal vestibuloplasty b) Open submucosal vestibuloplasty

2. Secondary epithelialization(Reepithelialization vestibuloplasty)

a) Kazanjian’s technique b) Clark’s technique 3. Grafting vestibuloplasty

CLOSED SUBMUCOSAL VESTIBULOPLASTY (OBWEGESER, 1959)

Can be done under local anesthesia

A vertical incision is made through the mucosa only which extend from mucogingival junction to labial mucosa

Blunt dissection is done to separate mucosa from submucosa

The vertical incision is then deepened to reach periosteum

Blunt dissection is then made in a subperiosteal plane and similar tunnels are created

A wedge shaped strip of connective tissue remains between submucosal tunnel and subperiosteal tunnel

This wedge shaped tissue is excised

Mucosa become freely movable

It is now adapted to the deepened sulcus and a stent is placed to retain the mucosa in that position

Stent is removed in one week when adequate healing has taken place

OPEN SUBMUCOSAL VESTIBULOPLASTY (WALLENIUS ET AL, 1963)

A horizontal incision is made through the mucosa only at the mucogingival junction

Mucosa is dissected or separated from the submucosa towards the lip so that a large mucosal flap is formed

MGJ

Subperiosteal dissection is then done to the desired extend of the vestibular deepening

Stay sutures are placed in the flap to fix it to the periosteum deep in the vestibule

The free margins of the flap are returned to their original position and sutured

Presence of adequate amount of bone and healthy mucosa is an important criteria to perform both mucosal advancement vestibuloplasty techniques

If mucosal flaps are adequately stabilized for about ten days, relapse is usually minimal

KAZANJIAN’S TECHNIQUE Incision is made on the labial mucosa

The labial and vestibular mucosa is reflected

Vestibule is deepened to the desired depth by supraperiosteal stripping

Mucosal flap is turned down from its attachment on alveolar ridge and is placed against the periosteum and sutured to its depth that is created

The labial or soft tissue surface is left to granulate and heal by secondary epithelialization

A stent is placed and left in place for atleast a week for healing to take place and to maintain the depth of the vestibule

This technique leaves a raw surface on the labial side of the sulcus to heal by secondary epithelialization

This soft tissue surface tend to contract as it heals

This could lead to further loss of sulcus depth

Inadequate depth of vestibule

Two vertical incisionsextending into the alveolar mucosa, joined by a horizontal incision

Releasing themucosal attachment by sharpdissection

Releasing the muscleattachment by periosteal elevator

Mucosal flap sutured tothe underlying periostium

Placement of aperiodontal dressing

Increased vestibular depth six weeks post surgically

LIPSWITCH VESTIBULOPLASTY Described by Kethley and Gamble. Also known as transpositional

vestibuloplasty

Modification of kazanjian’s technique

Adequate mandibular bone height is necessary

Labial incision is made and mucosal flap is raised from labial surface

Supraperiosteal dissection is done on anterior part of mandible

Periosteum is incised on the crest of the alveolar ridge and reflected away from the bone with lower edge attached

Free end of periosteum is sutured to denuded labial submucosal surface

Mucosal flap is sutured over denuded bone to inferior attachment of periosteum at the depth of the vestibule

This is known as transposition technique because labial flap and periosteal flap are interchanged or transpositioned to line the opposing surfaces

CLARK’S TECHNIQUE Horizontal incision is made on alveolar

ridge just buccal to crest of the ridge

A supraperiosteal dissection is done till the desired depth of the vestibule

The mucosa of the lip is undermined till the vermillion border

The free margin of the mucosal flap is sutured to the depth of the newly created vestibule

Clark's vestibuloplasty incision and reflection of the supraperiosteal flap

Therefore, the mucosal surface or the soft tissue side of the vestibule is covered with mucosa

Whereas on the osseous side the raw periosteal surface is left to granulate and epithelialize secondarily ; but this raw surface covering bone cannot contract

This is its advantage over kazanjian’s technique

Drawback of the technique is that relapse is common since the attachment of the lip musculature tot the alveolar bone shift towards the alveolar crest,obliterating the sulcus.

GRAFTING VESTIBULOPLASTY Done when there is inadequate labial

vestibular mucosa to deepen the vestibule

Clark’s vestibuloplasty can be done, followed by covering of the raw periosteal surface with a graft to hasten the healing procedure

Pre –op : Reduced vestibular depth

Half of the prepared bed was covered with alloderm and the other half with mucosal graft (immediately after surgery)

After 1 month

After 6 months

TECHNIQUE TO REMOVE FRENUM A frenum is a fold of mucous

membrane ,usually with enclosed muscle fibers, that attach lips and cheeks to the alveolar mucosa and gingiva .

Frenum become a problem if the attachment is too close to the marginal gingiva .Tension may pull the gingival margin away from the tooth.

This condition may be conductive to plaque accumulation and inhibit proper tooth brushing.

FRENECTOMY Complete removal of the

frenum ,including its attachment to underlying bone and may be required in the correction of an abnormal diastema between the maxillary central incisors.

FRENOTOMYRelocation of the frenum usually in more

apical position.

PROCEDURESTEP 1: After anesthetizing the area engage the frenum with a hemostat inserted to the depth of the vestibule.

STEP 2: Incise along the upper surface of the hemostat extending beyond the tip.

STEP 3: Make a similar incision along the under surface of the hemostat.

STEP 4: Remove the triangular resected portion of the frenum with the hemostat. This exposes the underlining brush like fibrous attachment to the bone .

STEP 5: Make a horizontal incision separating the fibers and bluntly dissect to the bone

STEP 6: If necessary extend the incision laterally and suture the labial mucosa to the apical periosteum.

STEP 7: Clean the surgical field and pack with gauze sponges until bleeding stops.

STEP 8: Over the area wit dry aluminium foil and apply the periodontal pack.

STEP 9: Remove the pack after two weeks and repack if necessary. One month is usually required for the formation of intact mucosa with the frenum attached in its new position.

A) Preoperative view of the frenum between two maxillary central incisors

B) Removal of frenum from both the lip and the gingiva

Site is sutured after it is placed over the wound postoperative view at 2 weeks

CONCLUSION Newer techniques are constantly being

developed and are slowly being incorporated into periodontal practice.

The practitioner should be aware that, at times, new methods are published without adequate clinical research to ensure the predictability of the results and the extent to which the techniques may benefit the patient.

Critical analysis of newly presented techniques should guide our constant evolution toward better clinical methods.

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