Mucogingival surgery
INTRODUCTION
- Mucogingival surgery covers the morphological development of the superficial periodontium, degraded by unfavorable anatomical conditions or by periodontal disease or in a context of tissue development.
- The surgical techniques used here make it possible to improve the quality of visible tissues and, as a general rule, to compensate for and prevent unsightly defects in the gums.
- It also aims to prevent the pocket epithelium from crossing the mucogingival line, which would lead to attachment failure.
1-Definition
- Mucogingival surgery is a plastic surgery that aims to correct the morphology, position and quality of the gingival tissue that borders the tooth.
- It is a subtractive or additive surgery intended to correct defects in the mucogingival tissues which complicate periodontal diseases and which can hinder the success of periodontal treatment.
2-OBJECTIVES
- Increase the area of attached gingiva when it is insufficient.
- Stabilize the progression of periodontal disease.
- Remove tension and traction on the edge of the free gingiva.
- Sufficient deepening of the bottom of the vestibule to allow effective brushing and good food deflection during chewing
- Combating dentin hypersensitivity
- Recreating a favorable environment for operative dentistry.
- Attempt root coverage.
3.Indications
3.1. Functional indications:
- Reposition the frenulum and muscle bands that interfere at the level of the free gum.
- Expand the area of adherent gingiva or create a new area of attached gingiva.
- Gum recession
- Preprosthetic surgery.
- Tissue arrangement before orthodontic treatment.
3.2. Aesthetic indications:
- Gingival recession especially in the maxilla in patients with a gummy smile.
- When the limits of prosthetic supports have become supra-gingival.
4. Contraindications
Absolute contraindications:
- In patients with severe heart disease, or malignant hemophilia.
- In patients at risk of bleeding: patients on anticoagulants or with severe bleeding disorders (hemophilia, WILLBRAND disease)
- In patients with reduced defense mechanisms against bacterial infection (AIDS, acute leukemia, etc.)
- Refuse any intervention in patients with absent, defective or insufficient oral hygiene
Relative contraindications:
- In pregnant women, surgery should be avoided during the 1st (risk of abortion) and last trimester (risk of premature delivery)
- In subjects suffering from diabetes or chronic nephritis, the agreement of the treating physician must be sought and the procedure performed under antibiotic cover.
- When teeth present advanced destruction due to caries (coronal or root) advanced periodontal disease requiring extraction.
Mucogingival surgery
5. The different surgical interventions
5.1. Gingival grafts
5.1.1. Pedicled graft
- Laterally displaced flap
1. Definition
- It is a surgical technique intended to cover and/or stabilize progressive and unsightly root denudations.
- The donor site is represented by the gingiva adjacent laterally to the site to be treated.
2. Indication
- Recovering from recessions.
- The contribution of gum to a tooth that has little or no gum to restore the mucogingival complex.
- The provision of keratinized tissue to an implant site.
- The release of the included canine in the vestibular position.
3. Technique
- The edges of the recession are prepared: the edge furthest from the donor area is freshened with the blade, which traces an external bevel, so as to expose the connective tissue.
- The incision pattern includes an intrasulcular incision on the donor site tooth and a horizontal incision at the base of the papillae, to remove a flap at least one and a half times wider than the recession.
- The discharge incision is vertical up to the mucogingival line, then obliquely towards the recession in the alveolar mucosa.
- Another incision in the mucosa in the extension of the recession frees the flap.
- The gingival tissue is lifted by full-thickness detachment.
- The flap is then moved laterally and tried on.
- The flap is finally sutured with a suspensory stitch and separated stitches on the external edge.
4. Advantages
- Relatively easy and quick to execute
- Tissue integration after healing is good
- There is only one operating area, with the donor site and the surgical site being located in contact with each other.
5. Disadvantages
- It only allows the treatment of a single recession
- Need for the presence of significant tissue quality near the lesion
- Bipapillary flap
1. Definition
Technique described by NELSON in 1987, it is associated or not with the use of a connective graft, allows the recovery of a unitary recession, with a single surgical site.
2. Indication
CL1 and 2 of MILER with presence of large papillae on either side of the recession.
3. Technique
- Half-thickness dissection of the 2 papillae on either side of the recession, the two flaps remaining pedicled and vascularized by their apical base.
- After dissection, they are moved laterally so as to cover the lesion.
- Suture them to each other as well as to the side edges.
4. Advantages
- Good aesthetic integration giving good clinical results.
5. Disadvantages
- A meticulous technique, the suture of the two papillae is delicate and has a weak point at its base.
- Limited indications because it requires the presence of large and thick papillae on either side of the recession.
- Coronally displaced flap
1. Definition
It is a mucogingival surgery procedure which consists of moving the gingival tissue present apically to the site to be treated in a coronal direction.
2. Indications
- For the recovery of MILLER class 1 recessions.
- In regenerative periodontal surgery: covering of a membrane, covering of a filling with bone or biomaterials.
- In ridge surgery: covering with a membrane or bone graft, or covering an alveolus filling with biomaterials.
- In implant surgery site coverage at stage 1.
3. Technique
- De-epithelialization of papillae
- Two vertical discharge incisions
- A horizontal incision located at the limit of the de-epithelialized zone of the papillae and associated with an intrasulcular incision at the level of the recession
- Detachment of the flap, the latter must be able to completely cover the recession without constraints
- Once positioned, the flap is sutured at the level of the de-epithelialized papillae and on the sides.
4. Advantages
- Simple technique, single surgical site, with satisfactory aesthetic integration.
5. Disadvantages
- Does not thicken or increase the height of the gums
- The 2 vertical discharge incisions may be visible after healing.
- Semilunar flap
It is a variant of the coronally displaced flap, described by TARNOW in 1986.
1. Indication
- MILLER CL1 recession, single or multiple.
- It is imperative that there be relatively thick keratinized tissue apically to the recession to be treated.
2. Technique
- Intrasulcular incision completed by an arcuate incision at the level of the LMG
- From the intrasulcular incision, a blade is used to perform a half-thickness dissection up to the semilunar incision.
- This releases a pedicled and vascularized flap not by its apical part but by its lateral edges.
- The flap is pulled coronally and applied to the recession, then protected by a dressing.
3. Advantages
- Simple and rapid technique, which can be used for single or multiple moderate CL1 recessions, mainly in the maxillary anterior sector.
4. Disadvantages
- Possibility of scar bands in the alveolar mucosa, at the site of the semilunar incision.
- Need for thick fabrics
- Apically displaced flap
This intervention is based on resective bone surgery techniques in the treatment of bone lesions induced by periodontitis.
The aim of treatment is to create by resection a bone architecture close to that observed in a healthy state, considering that it conditions the gingival morphology.
1. Indications
– Coronary elongation
– Gingival augmentation
– Surgical release of teeth retained or in the process of erupting in the alveolar mucosa.
– Peri-implant plastic surgery.
2. Surgical technique
- Full-thickness intrasulcular incision up to the mucogingival line and partial-thickness beyond the mucogingival line
- Two vertical releasing incisions mesially and distally to increase flap mobility.
- Full thickness flap detachment.
- Osteotomy-osteoplasty.
- Position the flap apically and suture.
5.1.2. Free graft
- Epithelial-connective tissue graft
1. Definition:
- Epithelial-connective tissue graft or full-thickness graft.
- The graft taken is total: keratinized epithelium + connective tissue.
- Technique consisting of taking a graft and then fixing it on a surgical site prepared for this purpose.
2. Indications
- The increase of keratinized tissue.
- Root coverage.
- The arrangement of toothless ridges.
- Peri-implant planning.
- Assistance with maxillofacial surgery.
- Association with laterally or coronally displaced flaps.
3. Contraindication
-poor quality of donor tissue.
– MILLER class 3 or 4 recessions.
-a large mesio-distal diameter at the level of the exposed root.
4. Surgical technique
- An impression can be taken to make a resin palatal plate which protects the donor site during the first postoperative week.
- The recipient site is anesthetized as well as the donor site.
- The donor site is most usually the palate in an area between the first molar and the second molar, it can also be tuberosity or at the level of an edentulous ridge.
- Root preparation can be completed by demineralization with citric acid in order to expose the collagen framework of the dentin and allow its fusion with the connective fibers of the graft.
The intervention includes three sequences:
- Preparation of the recipient site:
- The receiving bed extends laterally and apically to the denudation.
- For better nutrition of the graft, the site is prepared by giving it the shape of a trapezoid with a small cervical base.
- With a #15 blade directed perpendicular to the gum, two vertical incisions and one horizontal incision are made at the small base of the trapezium.
- A fine forceps with more cruentés lifts the alveolar mucosa and a scalpel is introduced with the blade directed towards the tooth and the partial thickness dissection of the gingiva is carried out up to the horizontal intrapapillary incision.
- A partial thickness flap is thus released in its cervical part and reclined in the apical direction.
- The flap is released to the desired apical extension and then sutured to the periosteum at the bottom of the vestibule (this reduces bleeding and postoperative pain).
- A pattern to the dimensions of the bed is cut out of a sheet of tin, a wax plate.
- Graft collection
- The tissue harvested is oversized by 1/3 compared to the template, in order to compensate for the retraction of the graft, it must be at least 1 mm thick to have a band of underlying connective tissue.
- Protection of the donor site with a hemostatic sheet, a dressing and a palatal plate.
- Placing the graft
- Application and suturing of the graft on the recipient site, it must be perfectly immobilized in order to allow the formation of a fine and regular clot between the recipient bed and the internal conjunctival face of the graft.
- Applying a surgical dressing.
5. Advantages
- Tissue supply (height and thickness) of large quantity.
- Reliability of transplantation.
- Non-painful sequelae at the recipient site.
- Simplicity of execution
6. Disadvantages
- Unsightly appearance.
- Healing by secondary intention of the donor site.
- Painful post-operative period at the donor site.
- Risk of complications.
Mucogingival surgery
- Buried connective tissue graft
1. Definition
It is the autogenous transplantation of essentially connective tissue, taken from a donor site to a recipient site.
2. Indication
- Root coverage
- Ridge filling
- Pre-prosthetic gingival thickening
- Treatment of gingival dyschromia
- Creation of taste buds
- Peri-implant plastic surgery
- Creation of keratinized tissue.
3. Surgical technique
- Root surface preparation:
- Mechanical: Flatten the convexity of the root surface with diamond burs so that the entire recession is in intimate contact with the graft.
- Chemical: citric acid, tetracycline hydrochloride, EDTA, it allows the decalcification of the surface and therefore releases the collagen fibers from the dentin which will bind to the connective fibers.
- Harvesting the connective tissue graft
- Trap technique
- Opening of an epithelial-connective tissue trap by dissection.
- Harvesting a connective tissue graft also containing adipose tissue.
- Closure of the wound.
- Technique of a de-epithelialized epithelial-connective graft
- After having taken a GEC as in the epithelial-connective graft, we proceed with the de-epithelialization:
- Before sampling, by peeling the entire epithelium with a round burr
- After harvesting, on the operating table with the blade parallel to the surface of the graft
3.1. Buried connective tissue graft technique associated with a coronally displaced flap. LANGER ET LANGER 1985
- Horizontal incision at the enamel-cement junction
- Vertical incision up to the alveolar mucosa
- Partial thickness flap elevation
- Harvesting connective tissue graft from the palate
- Coverage of the lesion with the graft up to the ECJ
- Partial coverage of the graft with the flap.
3.2. Buried connective tissue graft technique associated with a laterally displaced flap
- NELSON technique
- Horizontal incision at the level of the JEC
- Vertical discharge incisions
- Harvesting a connective tissue graft from the palate.
- Covering the lesion with the graft.
- Graft coverage by lateral displacement of the flap.
- HARRIS technique 1992
- Horizontal incision at the level of JEC.
- Vertical discharge and inter-radicular incisions mesial and distal to the teeth to be covered.
- Formation of a split flap
- Harvesting of connective tissue graft from the palate.
- Cover the recessions with the graft.
- Joining the tips of the flaps over the recessions.
3.3. ALLEN 1994 Envelope (tunnel) technique
- No vertical incisions
- Partial thickness intrasulcular incision
- Formation of a partial thickness flap “subepithelial envelope”
- Harvesting connective tissue graft from the palate
- Positioning of the graft in the subepithelial envelope
- Sutures
Mucogingival surgery
5.2. frenectomy-frenotomy
1.Reminder
- The frenulum is a fold of mucosa usually containing muscle fibers that attaches the lips and cheeks to the alveolar mucosa and underlying gingiva and periosteum.
- A frenum begins to cause problems when its attachment is too close to the marginal gingiva and may require its removal or repositioning during surgical procedures.
He can then:
- Pulling or exerting traction on the healthy gingival margin and promoting the accumulation of irritants,
- Detach the wall of a periodontal pocket and worsen its severity
- Hinder post-therapeutic healing, prevent proper adaptation of the gum and lead to the formation of pockets or even prevent proper tooth brushing
- Low insertion of a maxillary median frenulum may require its removal or repositioning during surgical procedures.
Topographic classification
- DEWEL in 1946
- The frenulum joins the interdental papilla
- The frenulum does not reach the dental papilla
- PLACEK
- Mucosal attachment: the insertion of the labial frenum belongs to the alveolar mucosa and is located at the limit of the mucogingival line
- Gingival attachment: the lower insertions of the labial frenum are embedded in the attached gingiva
- Papillary attachment: the labial frenum is inserted into the papillary gingiva
- Interdental attachment: the upper labial frenum joins the top of the gingival septum and merges with the bunoid papilla.
2.Definition
- Frenectomy: represents the complete removal of the frenulum from its vestibular insertion to the palatine or lingual papilla.
- Frenotomy: represents the partial removal of the frenulum, with dissection from the apex to the base.
3.Indication
- Brake pulling the marginal gingiva
- Abnormally large brake
- Brake related to a recession or diastema
- Disharmonious brake for aesthetics during a gummy smile
- Hypertrophic frenulum associated with orthodontic closure of an inter-incisor diastema.
- Short lingual frenulum.
Mucogingival surgery
4.Operating technique
4.1. Frenectomy
- Anesthetize the area.
- Grasp the frenulum by inserting a hemostatic clamp into the bottom of the vestibule.
- Make an incision along the upper surface of the hemostatic forceps, extending beyond its tip.
- Make a similar incision along the underside of the hemostat.
- Remove the triangular portion of the frenulum that was resected using the hemostatic forceps, this exposes the fibrous attachment underlying the bone.
- Make a horizontal incision that will separate the fibers, then gently dissect until they are detached.
- Clean the surgical field and cover with compresses until the bleeding stops.
- Sutures
- Cover with periodontal dressing.
- Remove the dressing after a week, the reattachment of the frenulum to its new position can be seen a month after the operation.
4.2. Frenotomy
- The dissection is carried out in a V shape on the gingival or mucosal side, and the fibers are removed at the height of the insertion.
4.3. Lingual frenectomy
- The intervention must allow sufficient lengthening of the lingual frenulum or its removal.
- It requires special attention because many noble anatomical structures such as the ranine veins, the lingual artery, the lingual nerve, the salivary ducts.
- After retro-incisive para-apical lingual anesthesia, the base of the tongue is infiltrated on the surface.
- If the frenulum is thin, a horizontal incision at the base may be sufficient.
- If the frenulum is thick and the tongue is attached to the floor of the mouth; a diamond-shaped frenectomy is performed.
- The technique
- The tongue is stretched upwards and backwards by the surgical aid or with the aid of a grooved probe.
- The frenulum is sectioned starting from the retro-incisal area, thus delimiting a diamond.
- All tissues of the diamond will be removed.
- The edges of the wound are brought together and sutured with a running stitch or simple stitches.
Mucogingival surgery
5.4. Vestibuloplasty
1.Definition
It consists of increasing the depth of a shallow vestibule, in order to remove tension at the level of the attached gum, facilitating good food deflection as well as adequate hygiene and brushing.
2.Indication
- Presence of one or more brakes or flanges with abnormally high insertion
- Absence of attached gum on an entire sextant
- Vestibular shortness.
3. Operating protocol
3.1. Mucosal dissection technique
- It is a mucosal flap traced from the LMG.
- The dissection is done using a scalpel blade, keeping it parallel to the bone table, leaving the periosteum adherent to the bone (partial thickness flap).
- When the desired depth is reached, the flap is sutured to the periosteum.
- Applying the surgical dressing.
3.2. “ROBINSON1963” window technique
- It is a mucosal flap also traced from the LMG.
- The flap is detached and gradually lowered to the bottom of the vestibule.
- At the base of the incision , a first deep horizontal incision is made, i.e. going up to bone contact, a second horizontal incision parallel to the first is made under the same conditions 2 mm from the first
- Using a curette and starting from one end, a flap of periosteum is lifted, leaving bare bone “this is the fenestration”.
- The flap is sutured to the periosteum apically to the fenestration, which would prevent coronal rise of the mucosal flap.
- A dressing is put in place and then renewed after 8 days.
6- Factors affecting the outcome of mucogingival surgery
– Tension due to high muscle straps
-Poor alignment of teeth
– Disturbed occlusion
-Mucogingival line
-After the elimination of inflammation the tissue tends to contract and attract the mucogingival line towards the crown reducing the distance between the mucogingival line and the enamel-cementum junction.
7-Postoperative care
- Removal of the dressing and stitches after one week
- Post -operative advice :
- Avoid allowing the food bowl to come into contact with the area to be operated on.
- Refrain from smoking for one week.
- During the first two weeks; avoid brushing the operated area, mouthwash is prescribed twice a day.
- From the 3rd ; the patient begins to brush the area with a very soft surgical brush.
- After one month, hygiene methods are resumed on all the arches.
- Drug prescription:
- A painkiller is prescribed immediately after surgery.
- Antibiotic therapy is not systematic unless medically indicated.
Mucogingival surgery
Conclusion
In recent years, the indications for the application of keratinized and attached gingiva have become more restricted and specified.
Not all gum recession requires treatment, but intervention is necessary in certain indications.
It should be noted that the practitioner’s experience is an important success factor in this type of intervention.
Mucogingival surgery
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.