MUCO-GINGIVAL SURGERY
- INTRODUCTION :
Mucogingival defects represent a fairly frequent reason for consultation due to the appearance of clinical signs or aesthetic damage, even if most often the durability of the teeth on the arch is not called into question, hence the need for therapy to remedy it. The aim of this therapy is to recreate periodontal health conditions.
- DEFINITION OF MUCCO-GINGIVAL SURGERY:
- According to the American Academy of Periodontology in 1977:
It is the set of plastic surgery techniques intended to correct or modify defects in morphology, position and the quality of the gingival tissue surrounding the tooth.
- It is defined as “all periodontal surgical techniques aimed at correcting defects in morphology, position and/or quantity of gums”.
Mucogingival surgery concerns the relationships between the adherent gingiva and the alveolar mucosa, i.e. the mucogingival junction, the frenum and the alveolar bone.
- THE DIFFERENT MUCO-GINGIVAL LESIONS:
- Absence of attached gingiva:
It is an anatomical defect rather than a mucogingival lesion. For many years, attached gingiva has been considered a fundamental element in maintaining periodontal health.
If the gingival height is assessed using a periodontal probe, the quality of a tissue and in particular its thickness are more difficult to quantify.
To characterize this thickness, one can use one of the 4 types described by Maynard and Wilson (1980):
- Type 01: thick alveolar processes, thick and wide keratinized gingiva (03-05mm)
- Type 02: thin alveolar processes, thin and reduced keratinized gingiva (less than 02mm)
- Type 03: thin alveolar processes, thick and wide keratinized gingiva
- Type 04: thin alveolar processes, thin and reduced keratinized gingiva
MUCO-GINGIVAL SURGERY
- Gingival hypertrophy:
It is a sign of gingival inflammation characterized by an increase in volume (thickness or height) of direct local etiology (bacterial biofilm) or systemic .
- Recessions:
It is a root denudation such that the top of the gum is located apically in relation to the cemento-enamel junction, this withdrawal appears most often on the vestibular surface, more rarely on the buccal surface and is frequently characterized by a non-inflammatory clinical state.
- THE OBJECTIVES OF MUCCO-GINGIVAL SURGERY:
- Restore deflective gingival architecture by preserving or creating adequate height of attached gingiva.
- Remove any frenulum or bridle at the gingival edges
- Combating dentin hypersensitivity
- Attempt root coverage (recessions)
- Facilitate hygiene by giving the vestibule a normal depth
- INDICATIONS FOR MUCCO-GINGIVAL SURGERY:
- Before ODF treatment: if it can modify the vestibular position of the teeth and if a mucogingival anomaly already exists
- In the case of pathological insertion of a frenulum or bridle which would hinder hygiene
- Persistence despite optimal bacterial plaque control by the patient of inflammation with progressive destruction of the attachment system leading to gingival recession
- When the aesthetic damage or the pain caused by the injury are intolerable
- CONTRAINDICATIONS OF MUCCO-GINGIVAL SURGERY:
These are the contraindications for all surgery: absolute contraindications: unmotivated patient; relative contraindications: patient with a general illness.
- THE DIFFERENT TECHNIQUES OF MUCCO-GINGIVAL SURGERY
- General principles:
Mucogingival surgery can only be performed after a sequence of etiological therapy aimed at suppressing inflammation and lowering the bacterial load
B-Frenotomy-frenoectomy:
- Brake definition :
A frenulum is a fold of mucosa containing muscle fibers that attach the lips and cheeks to the alveolar mucosa and/or to the underlying gingiva and periosteum. A frenulum is considered pathological when it has a high or low insertion; it can then pull or exert traction on the healthy gingival margin and promote the accumulation of irritants, it can detach the wall of a pocket and aggravate its severity or it can hinder post-therapeutic healing, prevent the proper adaptation of the gum and lead to the formation of pockets, or even correct dental brushing .
- Definition of frenum: Frenum is the complete removal of the frenum including its attachment to the underlying bone, such as may be necessary for the correction of an upper interincisor diastema.
- Definition of frenotomy : frenotomy represents the partial ablation of the frenulum (without fibrillar detachment), the latter being sufficient to move the attachment of the frenulum to create an area of attached gingiva between the marginal gingiva and the frenulum and therefore satisfy periodontal requirements.
- Goals of frenulumectomy:
- Orthodontic goal: to eliminate the etiology of anomalies and secondary malformation and prevent relapse
- Create an area of attached gingiva between the marginal gingiva and the frenulum
- Improve hygiene
- Promote healing and this for better adaptation of the gum against the dental wall
- Aesthetic
5- The technique
– Asepsis of the operating field
-Anesthesia on both sides of the frenulum.
– Lip stretching
– grasp the frenulum with the hemostatic forceps at the bottom of the vestibule
-incision on either side of the V-shaped clamp (gingival side and labial side and the base of the frenulum).
– remove the triangular part of the frenulum, which will expose the fibrous attachment underlying the bone.
-if the vestibule at this level is shallow it must be deepened using lateral incisions.
-disinsertion of fibers with a stripper.
-cleaning the wound.
– hemostasis.
-placement of a periodontal dressing which will be renewed after one week.
-post-operative advice
5- Healing:
- At the bottom of the vestibule: it is called first intention where the contact of the mucosa on the deep periodontium almost eliminates the detersion phase
- At the level of the triangle: it is of 2nd intention where the repair phase is delayed by significant detersion and its duration depends on the characteristics of the wound: surface area, depth, etc.
- Epithelialization occurs in 1 week
C-VESTIBULOPLASTY/DEEPENING OF THE VESTIBULE:
1- Definition:
Vestibuloplasty involves increasing the depth of a shallow vestibule in order to remove any tension at the marginal gingiva and to obtain an adequate and sufficient height of adherent gingiva, thus facilitating brushing and oral hygiene.
2-Indications :
– vestibular shortness
-presence of one or more brakes or muscles with abnormally high insertion.
-absence of attached gum over an entire area.
3-ROBINSON’S TECHNIQUE 1963:
-Asepsis, local anesthesia
-Creation of a mucosal flap traced from the muco-gingival line with the blade
No. 15 Leaving the periosteum adherent to the bone.
-the dissection is carried out using a scalpel held parallel to the external table.
– Pushing back the fibers apically using a stripper
– A periosteal fenestration will expose a strip of bone of approximately 0.5 mm.
-The flap is sutured at the bottom of the vestibule.
-Put in place a surgical dressing which will be renewed after a week to protect the wound.
D-FLAP INTERVENTIONS: DISPLACEMENT FLAPS:
1-Definition:
-a periodontal flap is a portion of gingiva and/or mucosa that has been surgically detached from the underlying tissues in order to provide the visibility and direct access that are necessary for treatment.
-periodontal flaps are said to be full thickness or mucoperiosteal when they include the periosteum detached from the underlying bone and partial thickness when they are dissected freely above, the periosteum leaving the latter with a part of the contiguous connective tissue attached to the bone
-the simple flap (non-repositioned flap) which is replaced in its pre-surgical position at the end of the operation.
-the repositioned flap which is replaced in a new position at the end of the intervention.
2- CORONARILY DISPLACED FLAP:
- Havey 1965
a-Indications:
– U, V, short single or multiple recession in the upper jaw of Miller class I and II.
b-Contraindications :
– insufficiency of attached gingiva
– Shallow vestibule
-Miller class III and IV recession
- Coronally displaced flap of BERNI MOULIN 1975 :
It is a variation of the Harvey flap, it is intended to cover one or more recessions.
- The semi-lunar (crescent) flap
a-Indications:
Miller Class I recessions, single or multiple, it is imperative that there be relatively thick keratinized tissue apically to the recession to be treated.
b-contraindications:
At the level of the mandibular anterior teeth, the flap cannot be moved coronally due to the narrowness of the mesiodistal diameter
c-the technique :
– partial thickness crescent flap, the incision will be oblique and concave in the coronal direction located a few millimeters from the gingival margin
-flap detachment.
-intra-sulcular incision going towards the first incision.
-coronal displacement of the flap and its intimate application on the dental surface.
-application of a surgical dressing.
3 – THE LATERAL DISPLACEMENT FLAP:
a-Definition:
This technique was described by GRUPE and WAREN in 1956 and consists of laterally moving a portion of keratinized gingiva provided that there is sufficient quantity and quality of keratinized gingiva at the donor site.
b- objectives :
This technique allows to cover a localized recession and to increase the height of keratinized tissue thanks to a pedicled flap from a site adjacent to the recession. The gum is moved (rotational movement) and sutured on the area to be treated.
c-Indications:
When the donor site has significant gingival thickness and height, to allow partial thickness dissection.
Edentulous areas or teeth in a lingual position are good donor sites because thick gingival tissue is most often available there.
d-Contraindications :
-Poor quality proximal attached gingiva
-Affect of the interdental septa.
e-Mixed technique:
Preparation of the recipient site:
-removal of the epithelium over approximately 3mm on the side opposite the donor site using an external bevel incision.
-an internal bevel incision on the adjacent side of the donor site.
-the two incisions join apically at the mucogingival line.
-mechanical and chemical root planing.
Donor site preparation:
-Incision located approximately two teeth from the recipient site, this incision is vertical up to the mucogingival line; it is superficial and parallel to the internal bevel incision of the recipient site while respecting the integrity of the gingival papillae and it continues in the alveolar mucosa by an angular and oblique incision on the side of the displacement.
-intra-sulcular incision following the gingival marginal edge.
-flap detachment: the flap will be mixed, the half adjacent to the recession will be a mucoperiosteal flap, while the other will be partial thickness.
The mucoperiosteal part will cover the recipient site and the bony surface of the donor site will remain protected by the periosteum.
-transfer and repositioning of the flap:
The flap is placed against the root surface and sutured on the mesial and distal sides of the periosteum.
The entire surgical area will be covered with a periodontal dressing which will be renewed after eight days.
4-THE BI-PAPILLARY FLAP (COHEN and ROSS 1968)
a-Definition:
It is a double lateral translation flap, it allows to move and suture two papillae located on either side of a recession if they are high and perfectly keratinized.
b-Indications:
Miller class I and II recession with presence of large papillae on either side of the recession.
c-The technique:
-preparation of the recipient site:
– Two incisions are made: one with an external bevel, the second with an internal bevel in order to superimpose two connective tissues with a sufficient contact surface when the two papillae come together.
These two incisions extend to the mucogingival line and remain superficial (mucous membrane).
-removal of granulation tissue
-root surfacing.
– preparation of the donor site:
– two vertical incisions, distal to the two adjacent papillae will be made, they are extended by two oblique incisions which reduce any tension at the level of the flaps.
-partial thickness flaps are detached leaving the periosteum and connective tissue on the alveolar bone.
-the approximation and coaptation of the flaps is done on the root surface at a height slightly more coronal than the bone limit.
-The sutures.
-application of a surgical dressing which will be renewed one week later.
3- healing:
Thanks to the double vascularization obtained with this type of intervention, the healing time is shorter than the lateral translation flap.
MUCO-GINGIVAL SURGERY
MUCO-GINGIVAL SURGERY
E- FREE GINGIVAL GRAFT (epithelio-conjunctival graft)
1-Definition:
It is the autogenous transplantation of mucosal tissue from a donor site to a recipient site (BJORN 1963, KINJ and PANNEL)
2-Indications:
-insufficient or absent height of attached gingiva, leading to a lack of depth of the vestibule, complicated by abnormal insertion of a frenulum or flanges thus creating a periodontal pocket.
-presence of gingival retraction accompanied by more or less significant exposure of the root surface with dentin hypersensitivity and aesthetic damage.
-insufficient or too thin attached gingiva before the creation of a prosthetic restoration
-increase in the height of the attached gingiva in the first instance, allowing the flap to be repositioned coronally or laterally in the second instance (BERNIMOULIN 1975).
3- contraindications:
– aesthetic: in the root coverage of the upper anterior teeth, especially if it is a gummy smile
-periodontal: in the presence of periodontal pockets
-technical: at the level of the 2nd mandibular molars, the external oblique line can constitute a nuisance
At the level of the maxillary molar sectors, limited access and visibility and the presence of buccinator muscle traction
In the ligular regions of the mandibular incisors, stabilization and vascularization are precarious.
-specific contraindications are: poor quality of donor tissue; Miller class III or IV recession; a mesio-distal diastema of the exposed root greater than the horizontal dimensions of the interproximal tissues.
4-The technique:
-Preparation of the recipient site: an internal bevel incision is made at the level of the gingival margin around the entire perimeter of the recession in order to eliminate the epithelium, the superficial portion of the connective tissue and the muscle fibers.
– choice of graft: the sample can be taken anywhere where there is keratinized tissue, particularly on the palate or on edentulous ridges.
– preparation of the donor site:
– it is necessary to use a template made of a sheet of tin plated on the recipient site and transferred to the donor site.
– the graft will be taken either with blade no. 15 or with the KLEWANSKY epitome or with the mucotome depending on the practitioner’s choice.
-the height of the template must be greater than that of the graft to compensate for post-surgical graft tissue contraction.
-its thickness should be 2 to 3 mm or thinner depending on the area taken and the area adjacent to the recipient site.
– it is recommended to use sutures on the graft before it is separated from the donor site since this can facilitate its transfer to the recipient site in order to immobilize the graft.
– the stitches should be placed in the periosteum or in the adjacent attached gingiva.
– tin foil is placed on the graft before applying the surgical dressing.
– the dressing must be renewed after a week and will be removed the following week with the sutures.
Note:
For the BERNIMOULIN technique or two-stage gingival graft:
This involves starting with a free graft at the bottom of the vestibule, then after healing a coronally displaced flap must be made.
F- THE BURIED CONNECTIVE GRAFT:
This technique has already been brought to light since 1985 by RAETZKE, LANGER but the most used is that of NELSON (1987), it is a connective tissue graft covered by a bipapillary flap such that the part of connective tissue which covers the root denudation is vascularized by bypass and also receives a vascular supply by the covering flap.
1-Advantages:
-Very predictable results.
-The graft is very highly vascularized by the internal face of the flap and the periosteum-connective tissue of the recipient bed.
-The palatal donor site of the connective tissue is closed after harvesting. Hemostasis is therefore easy and healing is rapid. Healing takes place with less discomfort and fewer painful reactions for the patient.
-The graft is very well adapted to the surrounding tissues and the aesthetic results are better.
-Method applicable to several adjacent recessions.
2-Disadvantages:
-Difficult technique.
-The graft is thick, so is the grafted tissue; gingivoplasty may be necessary to improve the aesthetic appearance of the surgical site.
3-Indications:
Coverage of exposed roots by Miller Class I and II periodontal recessions
4-Contraindications:
-Insufficient donor tissue thickness:
-The connective tissue graft for root coverage should be 1.5-2 mm thick, and the thickness of the palatal flap should be 1.5-2 mm after graft harvesting to avoid necrosis.
Therefore, at least 3 mm of palatal soft tissue thickness is required at the donor site.
MUCO-GINGIVAL SURGERY
MUCO-GINGIVAL SURGERY
G- The RTG
This involves interposing a regeneration membrane between the graft and the exposed root , whatever the root coverage technique (lateral translation flap, coronally displaced flap, etc.) and this is to increase the chances of regeneration of all periodontal tissues.
VIII- CONCLUSION:
The aim of surgery is to correct the morphology of the position and/or the quality of the gingival tissue, hence its indication, and to treat gingival recessions and recession.
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.