Frenectomy frenotomy vestibular deepening gingival grafts
Introduction : Mucogingival problems present a reason that very often leads the patient to consult mainly for aesthetic reasons. Mucogingival surgery techniques are very numerous. It is necessary to know the indications of each of these techniques, advantages and disadvantages as well as to master the technique of realization in order to be able to achieve the expected result of the envisaged periodontal therapy.
1-Definitions :
– Periodontal surgery includes surgical treatments performed on periodontal soft tissues and on alveolar bone.
-Muccogingival surgery is an extension of periodontal surgery which aims to recreate or maintain a volume of attached gum in relation to the dental organ.
Mucogingival surgery maneuvers – also called periodontal plastic surgery – aim to correct or prevent the appearance of recessions.
In 1992, the American Academy of Periodontology defined mucogingival surgery as “the set of plastic surgery techniques devoted to the correction of defects in morphology, position and/or quantity of gingiva around the underlying teeth.
The development of implant therapies involves the use of these techniques to manage peri-implant tissues. This definition can therefore be extended to the tissue management of dental implants.
-Definition of the frenulum : the frenulum is a fold of stretched mucosa between two anatomical structures.
-Definition of frenectomy : this is the term used in periodontal plastic surgery to designate the total surgical elimination of a frenulum.
-Definition of frenotomy: frenotomy consists of the partial elimination of a frenulum.
2-The objectives of frenectomy: The correction or elimination of an anatomical anomaly of the gingiva and/or the alveolar mucosa.
This surgery concerns
- The maxillary vestibular median frenulum
- The mandibular vestibular median frenulum
- The medial lingual frenulum
- Lateral vestibular brakes
3-Classification of the brake according to Placek et al.1974:
Class 1 : Mucosal attachment: the insertion of the maxillary labial frenum belongs to the alveolar mucosa and is located at the limit of the mucogingival line.
Class 2 : Gingival attachment: the lower insertions of the maxillary labial frenum are embedded in the attached gingiva.
Class 3 : Papillary attachment: the maxillary labial frenum is inserted into the papillary gingiva. In this case, lip traction causes a displacement of the marginal gingiva of the central incisors.
Class 4 : interdental attachment: the maxillary labial frenum joins the top of the gingival septum and merges with the bunoid papilla. This anatomical situation is generally related to the persistence of the interincisor diastema.
4-Indications for frenectomy:
Periodontal indications:
-Brake exerting traction on the marginal gingiva (opening of the gingivodental groove) and/or hindering hygiene
-disharmonious brake for the aesthetics of the gummy smile
-brake associated with periodontal pathology
Biomechanical indications:
-hypertrophic median frenulum and anterosuperior diastema
-short lingual frenulum
Indications for lingual frenectomy:
-Abnormally short lingual frenulum
– discomfort of the tongue in the range of lingual movements (inability to propel the tongue beyond the mandibular incisal edges).
-excessive tissue traction of the mandibular retro-incisal marginal tissues
-the association with an evolving retro-incisive recession
– plaque buildup due to inability to clean.
5-Operative techniques:
Vestibular frenectomy :
-vestibular para-apical anesthesia (palatal if necessary)
-the brake is highlighted by a strong grip of the lip and immobilized by self-locking tweezers
– the incisions in the attached gum 1 mm on either side of the attachment of the frenum on the gum delimit the two sides of a triangle whose gingival apex may possibly be in the interdental space or on the palatal surface, then a second triangle with an opposite apex is dissected on the internal surface of the lip, in the labial mucosa, using a gum chisel or blade. The common base of the two triangles corresponds to the mucogingival line of the adjacent teeth.
-all of the rhomboid tissue is resected.
-the brake attachment is detached, a diamond-shaped wound is obtained.
-the edges of the diamond are brought together by a series of discontinuous bridges or a running suture starting from the lip towards the gum. The triangular area of excision of the frenulum in its gingival part is protected by a cross suture.
In the presence of a palatal inserted frenulum, it is advisable to disinsert the fibers located in the intermaxillary suture using a periodontal curette.
When the frenulum is associated with a diastema, it was previously recommended to section the papilla and the interdental tissue which could have been responsible for the recurrence of the diastema.
Currently, especially when we know the difficulties of periodontal plastic surgery applied to the restoration of the papillae, it is advisable to respect the papilla.
Lingual frenectomy:
-retro-incisive lingual para-apical anesthesia, and anesthesia of the base of the tongue.
-a horizontal incision at the base of the frenulum is sufficient if it is thin.
-the tongue is stretched upwards and backwards by the surgical aid or with the aid of a grooved probe or by a suture which pierces the tip of the tongue.
-when the frenulum is thick, make a diamond-shaped incision associated or not with horizontal incisions at the base of the tongue.
-The edges of the wound are brought together and sutured with a running stitch or simple, separate stitches.
If speech disorders are associated, it may be necessary to prescribe speech therapy of the tongue.
Benefits:
-fast and effective action
-less painful after-effects
Disadvantages:
-operative difficulty for the lingual frenulum
-risk of unsightly scarring and discomfort (rare)
Vestibuloplasty (vestibular extension procedure):
The procedures used to modify the shape of the vestibule are grouped under the term vestibuloplasty.
Goals:
-increase the vestibular depth in order to provide adequate space to increase the attached gingival area.
-increased depth can also facilitate improved oral hygiene and gum health.
Vestibular extension using a partial thickness (mucosal) flap (mucosal dissection or stripping):
-place a blade against the gum, directing the tip in an apical direction, and insert it inside the muco-gingival junction at one end of the operating field.
-the blade is moved along the mucogingival junction to separate a flap consisting of epithelium and a thin layer of underlying connective tissue, which allows the vestibule to be deepened at the same time.
-When the desired depth is reached (approximately twice the desired attached gingival surface), the flap is pushed in an apical direction until its edge reaches the newly established vestibular depth.
-clean the wound
-the edge of the flap can be attached to the periosteum by a suture made at the base of the surgical field. Bleeding is controlled by compression of the area.
-a dressing is put in place.
Gingival grafts
Definition : A graft is a transposition of tissue from one site to another in the same individual or between two different individuals.
The transplanted graft can be gum tissue or bone tissue.
Grafting involves the presence of a donor site capable of healing and the presence of a recipient site requiring an increase in tissue volume. The graft is either connective or epithelioconnective.
A-Coronally positioned flaps
The technique was first described in 1958 by Patur and Glickman
Goals:
-cover a recession
-cover a membrane following a bone graft filler or guided tissue regeneration.
Principle:
-use the attached gingiva located apically to the recession to cover it.
Directions:
-single or multiple Miller class 1 recessions
-presence of a sufficient volume of keratinized tissue located apical to the recession
-keratinized tissue thickness of at least 0.8mm.
-in regenerative periodontal surgery (covering a membrane, covering a filling with bone or biomaterials)
-in ridge surgery (coverage of a membrane or bone graft or coverage of an alveolus filling with biomaterials)
-in implant surgery (site coverage)
Benefits:
-60 to 99% recovery according to studies
-predictable results for Miller classes 1
-pedunculated flap therefore vascularized
-simple technique to implement
-a single surgical site
-good aesthetic result
-first intention healing
-very moderate post-operative pain
Disadvantages:
-indicated for Miller Class 1 only
-risk of failure for the thin periodontium
-recurrence if the etiological factors are not controlled
-no increase in volume of keratinized tissue
-possible unsightly scar bands from discharge incisions
Technical:
1-previously carry out measurements with the periodontal probe to assess the extent of the desired movement
2-anesthetize
3-trace the future papillae with blade No. 15, spaced from the top of the initial papilla by the same height as the recession to be covered
4-draw the discharge incisions in a parallel manner, looking for bone contact
5-once the mucogingival line is passed, make oblique incisions in the alveolar mucosa (increase the laxity of the flap)
6-detach a full thickness flap up to the mucogingival line
7- continue the partial thickness dissection in the alveolar mucosa
8-check the position of the flap
9-gently surface the exposed cementum
10- de-epithelialize the initial papillae (blade or scissors)
11-start the sutures with O-shaped stitches suspended above the contact points of the tooth
12-suture the parallel discharges with O stitches
-variants:
Multiple LPCs: This technique is essentially the same as the LPC but involves several recessions on a block of contiguous teeth.
Two-stage LPC: technique consisting of performing an epithelioconnective graft apical to the recession then, after 2 months of healing, implementing the LPC. This technique described by Bermimoulin in 1975 has a coverage rate of 36 to 74% and is not very aesthetic.
LPC combined with connective tissue graft.
- Semilunar flap:
The semilunar flap is a covering technique involving the displacement of the apical attached gingiva. As such, it falls into the group of coronally positioned flaps.
It was initially described by Tarnow in 1986.
Objective:
– Cover Miller Class 1 recessions.
Principle
Release a partial thickness flap of attached gingiva located apically to the recession, then move it coronally to cover this recession. The flap remains pedicled mesially and distally.
Directions:
-Simple Miller Class 1 recession.
-Presence of a sufficient volume of keratinized tissue located apical to the recession.
-Maxillary anterior sector.
Benefits:
-Recovery percentage between 70 and 91% depending on the studies
-3 to 3 mm coverage gain
-Absence of discharge and periosteal incision
-Absence of suture
-Pedicled flap, therefore vascularized
-A single surgical site
-Good aesthetic result
-Very moderate postoperative pain.
Disadvantages:
-Delicate technique to implement.
-Miller Class 1 only, and in the anterior maxillary sector only.
-Sometimes unpredictable technique.
-Risk of failure in the case of dehiscence or bone fenestration.
-Technique contraindicated for thin periodontiums.
-Absence of increase in volume of keratinized tissue.
-Presence of a second intention healing zone.
Technical:
1-assess the extent of the desired movement using a periodontal probe
2-anesthetize
3-gently surface the exposed cementum
4-draw an arcuate incision starting at the base of the first papilla and joining the base of the second papilla (the incision must be parallel to the line of the gingival scallop of the tooth and extend apically beyond the mucogingival junction line. The flap must have a thickness of at least 2mm in order to respect its vascularization)
5-incise in the sulcus and continue with a partial thickness dissection to reach the first incision
6-pull the released flap without tension in the coronal direction and place it in the desired position
7-compress using a compress soaked in physiological serum for 3 minutes.
Variant:
This technique can be performed in the same operation on several adjacent teeth.
B-Laterally positioned flap (LPL):
The laterally positioned flap is a technique with more than 50 years of experience.
It was initially described by Grupe and Waren in 1956 and is derived from the skin plastic surgery technique of Ruben et al. As well as Smuckler and Goldman took up this technique and improved it by the double thickness of the flap.
Zucchelli et al. then highlighted the major concepts determining the success of this technique.
Goals:
-Recover a recession.
-Provide keratinized tissue next to a natural tooth or an implant.
Principle:
-Use the attached gingiva located lateral to the recession to cover the latter by translation of the flap.
Directions:
-Simple recessions Miller class 1 or 2.
-Presence of a sufficient volume of keratinized tissue from the adjacent donor site, i.e. a height of at least 3 mm and a thickness of at least 1.2 mm.
Benefits:
-Percentage of recovery between 60 and 70 according to the studies.
-Increase in the volume of keratinized tissue
-Pedicled flap therefore ensuring good vascularization and limiting the risk of necrosis
-A single surgical site
-Good aesthetic result
-Very moderate postoperative pain
Disadvantages:
-Delicate technique to implement.
-Risk of recession at the donor site.
-Presence of a second intention healing zone.
-Poorly suited to multiple recessions.
-Risk of recurrence in the presence of brakes or bridles.
-Requirement for a large volume of adjacent keratinized tissue.
Frenectomy frenotomy vestibular deepening gingival grafts
Technique:
-anesthesia
-gently surface the root
-make the incisions with blade 15 at the level of the recession
-intrasulcular incision which continues in an internal bevel in an angled manner beyond the mucogingival junction line and thus delimits the proximal edge of the flap.
-external bevel incision starting at the base of the contralateral papilla and joining the apical tip of the last incision to create a 2 to 3 mm wide raw zone. The triangle thus formed at the base of the recession is de-epithelialized.
-make the flap incisions:
- Scalloped horizontal incision in the gingiva starting from the base of the papilla of the tooth with the recession and leaving at least 2 mm of attached gingiva around the adjacent teeth. This incision delimits a flap one and a half times wider than the recession to be covered
- Discharging incision that is made up to the mucogingival junction line and continues with an oblique incision in the alveolar mucosa converging at the recession.
-raise the flap starting with a full thickness detachment beginning proximal to the recession
– incise the periosteum of the flap and dissect in partial thickness distally and apically to the defect. All the fibers holding the flap are thus released.
-the flap is moved passively over the area to be covered.
-suture the flap starting with the mesial angle, then the papillae, suture the mesial discharge, then make periosteal stitches at the level of the distal discharge.
Variation : in 1987, Nelson proposed to associate a connective tissue graft with the laterally positioned flap.
- Double papilla flap:
The double papilla flap belongs to the family of laterally positioned flaps.
The technique was described by Cohen and Ross in 1968.
Objective:
-Miller Class 1 and 2 Recession Recovery.
Principle:
Use the attached gum located on either side of the recession to cover it.
A convergent lateral displacement of the two parts of the flap allows this coverage.
Directions:
-Miller class 1 recession, or even narrow class 2.
-Presence of a sufficient volume of keratinized tissue at the sites bordering the recession.
-Two healthy papillae on either side of the defect.
Benefits:
-Pedicled flap therefore vascularized.
-A single surgical site.
-Good aesthetic result.
-Very moderate postoperative pain.
-Limits the risk of recession in adjacent teeth.
-No risk of bone exposure thanks to partial thickness dissection.
Disadvantages:
– Uncertain recovery.
-Unit recession only.
-Need for sufficient volume of keratinized gingiva bordering the recession.
-Presence of secondary intention healing zone.
-Delicate technique to implement.
Frenectomy frenotomy vestibular deepening gingival grafts
Technique:
-measure the recession and preview the flap
-anesthesia
-gently surface the exposed cementum
-incise intrasulcularly then in an arcuate fashion at the base of the papillae
-make the slightly converging discharge incisions up to the mucogingival junction line
-de-epithelialize the triangle created at the apex of the recession
-dissect the flap in partial thickness down to the alveolar mucosa
– passively position the two parts of the flap, covering the recession
-suture the two parts of the flap with O stitches, starting with the coronal stitch
-suture the flap to the recipient site at the level of the papillae, and if necessary, stabilize it with periosteal stitches.
Variation : it can be associated with a conjunctival graft. This technique was described by Nelson.
Epithelioconnective tissue graft:
It was first described in 1902 by Younger, and taken up again in 1963 by Bjorn, who made it one of the main techniques of periodontal plastic surgery.
Goals:
-Increase the volume of keratinized tissue
-Stop the progression of recession due to the action of traumatic bridles and feints and cover them.
-Deepen a vestibule.
-Promote prosthetic and implant periodontal integration by creating a keratinized attached gingival zone capable of resisting the trauma of chewing and brushing.
-Allow the creation of primary healing sites during soft tissue surgery maneuvers. The graft is then used as a biological dressing.
-Remove gum tattoos.
Principles:
-Prepare a recipient site by creating a bed of connective tissue.
– Take a graft of keratinized tissue from a suitable area.
-Stably suture the epithelioconnective tissue graft to the recipient bed.
-Protect the sampling site with a protective plate.
Directions:
Presence of one or more Miller class 1 or 2 recessions induced by traumatic bridles and feints.
Presence of low height of attached gingiva in a site requiring implant or prosthetic therapy.
Site with little or no aesthetic implications.
Presence of a sampling site with a sufficient volume of keratinized tissue.
Benefits:
Recession recovery percentage between 52 and 96% depending on the studies.
Significant increase in the volume of keratinized tissue.
Reproducibility and stability over time.
Disadvantages :
– Unaesthetic technique: the graft has a “patch” appearance of the same color as the generally lighter harvest site. The vestibular gingiva is parakeratinized while the palatal gingiva is orthokeratinized, which explains this difference.
-No recovery possible for Miller classes 3 and 4.
-Need for a good quality donor site.
-Anatomical risk linked to the presence of the palatine artery close to the donor site.
-Second-intention healing at the donor site, often associated with pain.
Technique :
Preparation of the recipient site
1- Manually mobilize the cheek or lip which facilitates visualization of the LMG and dissection.
2- Anesthetize the site by para-apical infiltrations. The swelling then observed in the free mucosa promotes the visualization of the IMG;
3-Incise with a 15 blade intrasulcularly the teeth to be treated or parallel to the LMG
4-Continue the incision horizontally, coronally to the mucogingival junction line, tilting the scalpel blade so as to bevel the edges of the recipient bed.
5-Make two discharge incisions extending apically into the mucosa.
6-start the partial thickness incision at one of the coronal angles of the flap with a 15 blade.
7-continue the apical dissection, taking care to eliminate all fibrous and muscular tensions
8-manually manipulate the soft tissues to ensure that no mobility appears at the level of the prepared connective bed
9-suture the attached gingival strip of the flap apically to the recipient bed with periosteal O stitches (absorbable thread).
10- measure the dimensions of the site precisely with the probe and make a template with the packaging cardboard of the wire to the exact dimensions of the receiving bed
11-place a compress soaked in physiological serum during the collection phase to prevent the formation of a clot.
Graft collection :
Principles to be respected:
The most common sampling is done at the palate
This should not extend beyond the distal face of the first maxillary molar so as not to risk damaging the palatine artery.
Place the graft immediately in physiological serum to limit its dehydration.
1- Begin the incisions by passing the blade horizontally more than 2 mm from the free gum following the contours of the template. This incision delimits the base of the graft
2- Finish delimiting the graft by following the edges of the template. The incision is made in depth, perpendicular to the bone, without seeking bone contact.
3- Insert the blade parallel to the bone surface and dissect the graft in partial thickness starting from the mesiocoronal angle. Ensure a thickness of at least 1.5 mm.
4- Hold the graft with dissecting forceps in order to cover it and allow the dissection to be controlled with blade 15.
5- Once the graft is detached, place it on a compress soaked in physiological serum in order to examine it and touch it up if necessary.
6- Immediately after collection, perform the first phase of hemostasis by compressing the site with a compress soaked in physiological serum. Once the bleeding has decreased, place a collagen compress and then insert the palatal plate to compress it.
Graft placement : should be done as quickly as possible.
1-check the perfect adaptation of the graft by ensuring that the connective tissue face of the graft is correctly placed against the connective tissue bed of the recipient bed
2-at the level of one of the coronal angles, make a first pass of the suture thread and make the first positioning stitch in O, this stitch is made in a papilla.
3- suture the graft with papillary stitches to stabilize it in the desired position.
4-make vertical periosteal stitches at their base and suspended around the teeth to be treated. The periosteum being secured to the underlying bone, it allows the stitches to be fixed (these stitches are intended to hold the graft against the recipient bed)
5-finally, make a crossed vertical quilted stitch.
6-check the immobility of the graft by manipulating the surrounding soft tissues
7-perform compression of the site for at least 5 minutes to limit clot formation and promote revascularization.
Frenectomy frenotomy vestibular deepening gingival grafts
Coronally positioned flap associated with a connective tissue graft:
Goals:
-recovery from a recession
-pre-prosthetic gingival thickening
– filling of edentulous ridges
-peri-implant gingival thickening
– creation of keratinized tissue
-improvement of aesthetics during loss of papilla
Principles:
-the graft is interposed between the bone surface covered with periosteum and the connective tissue surface of the epithelial connective tissue flap.
Directions:
-Miller class 1, 2, and 3 recession (limited prognosis)
-presence of an anterior vestibular bone defect not contraindicating the placement of an implant or the creation of a bridge pontic but hindering aesthetics.
-presence of thin, weakly keratinized gums next to a prosthetic crown that is not very resistant to attack.
Benefits:
-good aesthetic result
-good result for the recovery of recessions
-risk of graft necrosis limited by the revascularization which takes place on both sides of the graft
-very numerous indications
Frenectomy frenotomy vestibular deepening gingival grafts
Disadvantages :
-operative difficulties for partial thickness dissection and for graft harvesting
-risk of necrosis of the donor site
Connective tissue sampling using the Bruno technique : the sites for connecting tissue sampling were initially described by Edel in 1974. There are 3 of them: the tuberosities, the edentulous ridges and the palatine vault.
The most common site is the palate. Several techniques are used to perform palatal sampling: the trapdoor technique, parallel incision technique and Bruno technique.
Goals:
-recover a desired amount of connective tissue
Directions:
– connective tissue grafting to thicken tissues or cover recession
Benefits:
-unlike the trap technique, the flap made in the palate is pedicled by three of its four edges, which reduces the risk of necrosis and minimizes postoperative consequences.
– significant amount of connective tissue
-first intention healing
Disadvantages:
-delicate technique to perform
-risk linked to the presence of the palatine artery
– the volume taken being significant, a healing period of at least 3 months must be observed before any new sample is taken
Technical:
1- analyze the exact sampling area and evaluate the location of the palatine artery.
2-widely anesthetize the sampling area
3-make a first horizontal incision perpendicular to the bone surface and its contact. This is in a coronal position at least 2 mm from the sulcus of the teeth and does not exceed the distal face of the first maxillary molar.
4-Introduce the 15 mm scalpel blade into the first incision almost parallel to the axis of the tooth up to the apical bone contact previously evaluated. The partial thickness penetration of the blade thus preserves a thickness of superficial epithelioconnective tissue.
5-dissect the entire envelope looking for the apical bone contact
6-once the thinning has been carried out, while keeping blade 15 in the envelope, make two vertical incisions up to bone contact mesially and distally of the site.
7-release the graft, thus isolated by detaching the periosteum using a fine detacher, starting with the coronal part
8-gently remove the connective tissue with dissecting forceps, taking care to remove any fibers that are still attached.
9-place the graft in a physiological serum solution
10-compress the sampling site with a compress soaked in physiological serum
11-make suspended sutures so as to stick the envelope to the site
NB : the preferred sampling area is located between the canine and the center of the first molar. Indeed, this sector has the advantage of having a sufficient distance between the neck of the teeth and the palatine artery as well as a generally significant thickness of connective tissue.
Frenectomy frenotomy vestibular deepening gingival grafts
Variants:
The trap technique : consists of removing a thickness of connective tissue by making a trap with three free edges in an “open book” shape. The removal is therefore made easier and allows the periosteum to be preserved by dissection of the connective tissue.
The parallel incision technique is performed using an instrument on which two parallel scalpel blades are mounted, called a “Harris double-blade scalpel.” The sample is quick to perform and of constant thickness. However, the coronal part of the sample contains epithelium which is subsequently eliminated. The postoperative outcomes are less good than for the Bruno technique.
Envelope flap (connective tissue grafting using the envelope technique) : developed by Raetzke in 1985
Principle : the principle is to interpose a connective tissue graft between the denuded root surface and a previously prepared epithelial flap. The latter is made without a vertical releasing incision, so that a real “pocket”, or envelope, into which the connective tissue graft is slipped is formed all around the area to be covered.
Frenectomy frenotomy vestibular deepening gingival grafts
Indication:
-this technique is originally reserved for single RT1 Cairo recessions with sufficient surrounding keratinized tissue to allow partial thickness dissection.
Frenectomy frenotomy vestibular deepening gingival grafts
Technical:
-careful surfacing of the exposed root
-a partial thickness incision is made from the sulcus of the tooth and all around the recession in order to create a real pocket (with a 15c blade)
-this pocket is continued on either side of the recession over a width double that of the recession
– taking a graft of a size adapted to the pocket.
-slide the graft into the pocket
-simple digital compression is sufficient to immobilize the graft
-suspended stitches around the neck of the tooth allow slight coronal traction and intimate plating of the graft on the root surface
Tunnel flap : In order to treat multiple recessions, Allen adapted the envelope technique.
Benefits:
-like all displaced flap techniques associated with connective tissue grafts, this technique presents excellent results in terms of coverage, its main interest lies in the very quickly obtained aesthetic results.
Disadvantages:
-risk of perforation of the flap during dissection and partial coverage of the graft.
Frenectomy frenotomy vestibular deepening gingival grafts
Technical:
– This technique consists of joining several contiguous envelopes while continuing the partial thickness dissection under the papillae in order to create a tunnel
-the connective graft is inserted into the tunnel with a sharp instrument through the most significant recession.
-a mattress stitch attached to one end of the tunnel and to the graft can help guide and facilitate its insertion.
-once in place the graft is sutured with simple papillary stitches at the ends and vertical sutures at the other papillae
– non-periosteal apical sutures suspended around the neck of the teeth allow the assembly to be held in place and the tunnel to be pulled coronally in order to cover the connective graft as much as possible with the flap.
Frenectomy frenotomy vestibular deepening gingival grafts
Bibliography:
-Borghetti
– Francois Vigouroux Practical guide to periodontal surgery El sevier MASSON
-V. Monnet –Corti, C. Goubron, C.Fouque, S.Melloul, H.Lugari, JM.Glise, S.Vincent-Bugnas. Periodontal plastic surgery: indications and techniques EMC oral medicine 28-669-H-10
Frenectomy frenotomy vestibular deepening gingival grafts
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