Periodontal plastic surgery (or mucogingival surgery ):
- INTRODUCTION:
Mucogingival problems represent a major 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. Mucogingival surgery techniques have evolved considerably over the last 30 years.
A perfect knowledge of the techniques, their indications and limits is essential in order to establish, faced with a given lesion, the objectives of the treatment and the results which can be obtained in view of the current scientific literature.
- GENERALITIES
- Definition:
Mucogingival surgery is defined as “all periodontal surgical techniques aimed at correcting defects in the morphology, position and/or quantity of the gum”.
- Anatomical reminders
The periodontium is made up of four components which are: the gingiva, the periodontal ligament, the alveolar bone and the cementum.
When root denudation occurs, all the constituent elements are altered, resulting in exposure of the root cementum, destruction of the alveolar bone and the surrounding fibers.
- The different mucogingival lesions:
- Absence of attached gingiva.
- Gingival hypertrophy.
- The recession.
- The objectives of mucogingival surgery
Mucogingival surgery is performed in addition to regular pocket removal procedures or as an independent intervention with the aim of:
1-Increase the area of attached gum when it is insufficient;
2-Stabilize the progression of periodontal disease
3-Remove tension and traction on the edge of the free gum
4-Sufficient deepening of the bottom of the vestibule to allow effective dental brushing and good food deflection during chewing
5-Combat dentin hypersensitivity
6-Recreate a favorable environment for operative dentistry
7-Attempt root coverage.
- Indications and contraindications for mucogingival surgery:
- The indications:
-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 adherent gingiva;
-covering of gingival recessions;
-Pre-prosthetic surgery;
-Tissue development before orthodontic treatment;
-Aesthetic indications:
-Gingival recession especially in the maxilla in patients with a gummy smile;
-When the limits of the prosthetic supports have become supra-gingival.
- Contraindications:
-Personal hygiene not acquired;
-General condition:
We need to know whether the patient’s state of health allows us to intervene or not.
-Cardiovascular diseases: myocardial infarction, or anticoagulant treatment.
-Hematological diseases: acute leukemia, agranulocytosis, severe anemia;
– Hormonal diseases: unbalanced diabetes; patients taking immunosuppressants.
-HIV;
-Irradiated patients.
-Local contraindications:
-In the case of established, non-stabilized, progressive lesions;
-In the case of teeth that are too vestibular.
- Surgical techniques:
GENERAL PRINCIPLES:
Mucogingival surgery can only be performed after a sequence of etiological therapy aimed at suppressing inflammation and lowering the bacterial load.
- RESEARCH TECHNIQUES:
- Gingivectomy (see gingivectomy course).
- Frenulumectomy:
. Objective
Limit muscle traction on the gum. This procedure mainly concerns the maxillary and mandibular medial labial frenums, but also the lateral frenums and the lingual frenum.
· Indications
– In case of hyperplastic frenulum and/or causing significant traction and mobilization of the gingival tissues.
– In cases of maxillary interincisal diastema with insertion of the frenulum at the palatal level in the region of the retro-incisive papilla.
This procedure is most often performed alone or in combination with a gum graft.
· Benefits
Simple and rapid technique with reduced post-operative effects.
· Inconvenience
There is a risk of recurrence if the frenulum dissection is not completely performed.
. Surgical technique:
- Asepsis of the operating field.
- Periapical anesthesia on either side of the frenulum.
- Grasp the brake using a hemostat.
- Vestibuloplasty:
-Definition :
It consists of increasing the depth of a shallow vestibule, in order to eliminate tension at the level of the marginal gingiva, and to obtain an adequate and sufficient height of attached gingiva facilitating good food deflection as well as adequate hygiene and brushing.
-Indications:
– presence of one or more brakes or flanges with abnormally high insertion;
-absence of attached gum over an entire sextant;
-vestibular shortness;
There are two techniques: ROBINSON’s and the periosteal fenestration technique.
- FLAP TECHNIQUE
Pedicled gingival grafts are classified according to flap displacement:
1- Laterally rotated or displaced flap: -repositioned laterally or transpositioned,
-bi papillary;
2- Flap displaced or repositioned without rotation or lateral displacement: coronally displaced and semilunar flap.
All these techniques require careful and non-aggressive mechanical surfacing of the root. Root preparation can be completed by burnishing using a chemical agent.
The choice of technique:
It should be guided by the desire to best predict the outcome but also to minimize the number of surgical interventions:
-Height and width of the recession: the larger the surface to be covered, the better the vascular support of the grafted tissue must be, hence the interest in the pedicled or buried graft;
-Height of the keratinized tissue at the level of the recession and adjacent teeth: this tissue can, if it is of good quality, be pulled coronally or laterally;
-The depth of the vestibule: if the vestibule is shallow, the surgical covering technique must also recreate a muco-gingival complex compatible with good plaque control;
-The number of recessions: in order to avoid multiplying the number of interventions, the greatest number of recessions is treated in one session.
- GRAFT TECHNIQUES:
- free gingival graft: Non-buried or epithelial-connective grafts.
It is the autogenous transplantation of mucosal tissue from a donor site to a recipient site.
Indications
1- Increase in keratinized tissue
2- Root coverage;
3- The development of toothless ridges and increase in their volume;
4- Peri-implant planning;
5- The biological dressing: filling an alveolus after extraction;
6- Complement to maxillofacial surgery: correction of cleft palates or after-effects of the operation;
7- Association with laterally displaced flaps.
Contraindications
-Medical;
-Aesthetic: in the root coverage of the upper anterior teeth, especially if it is a gummy smile;
-Periodontal: in the presence of pockets or isolated recessions, it is preferable to create an apically positioned flap. When the gum adjacent to the recession is inflamed;
-Technical:
– at the level of the 2nd mandibular molars, the external oblique line can constitute a hindrance;
-at the level of the maxillary molar sectors, limited access and visibility and the presence of traction of the buccinator muscle.
· Goals
Two main objectives can be sought:
– increase in gingival height and thickness;
– coverage of periodontal recessions in Miller classes I and II.
· Indications
In sectors without major aesthetic implications. It allows the treatment of simple or multiple recessions, and vertical increases of ridges.
Technical
Described by Bjorn in 1963, it consists of placing an epithelial-connective graft taken from the palate in the area to be treated.
The different operating times are:
– preparation of the recipient site: to allow vascularization of the graft
– creation of a template to record the dimensions of the site to be treated;
– at the palatine level, the donor site is generally located at the premolar/first molar level in order to respect the path of the palatine artery.
– the tissue taken is oversized by one third compared to the pattern, in order to compensate for the retraction of the graft linked to the contraction of the fibers
– protection of the donor site by sutures, and placement of a surgical dressing or a thermoformed gutter;
– at the palatine level, the donor site is generally located at the premolar/first molar level in order to respect the path of the palatine artery
– the tissue taken is oversized by one third compared to the pattern, in order to compensate for the retraction of the graft linked to the contraction of the fibers
– protection of the donor site by sutures, and placement of a surgical dressing or a thermoformed gutter;
– application and suturing of the graft on the recipient site: it must be perfectly immobilized using lateral and periosteal sutures, in order to allow the formation of a fine and regular fibrin clot between the periosteal bed and the internal connective surface of the graft;
– application of a surgical dressing.
Periodontal plastic surgery (or mucogingival surgery ):
- Buried connective tissue grafts
Technical
It was described by Langer in 1985.
· Indications
It allows the treatment of multiple Miller class I and II recessions.
Goals
They are threefold: root coverage, increase in the height and thickness of the gum .
– Benefits :
Technique usable for multiple recessions of Miller classes I and II.
– Disadvantages :
Due to the presence of vertical discharging incisions, the lateral vascularization of the operative area is reduced.
- ADVANCED TECHNIQUES
Guided tissue regeneration:
· Goals
Guided tissue regeneration aims to reconstitute the entire attachment system, unlike other techniques which promote repair, with the creation of a long junction epithelium in contact with the root surface.
· Indications
The use of a membrane limits this technique to single recessions, in the presence of thick tissues that can be pulled coronally. The objective is therefore twofold: regeneration of the attachment system and recovery of the recession.
· Benefits
Regeneration of the attachment system.
· Disadvantages
– Cost.
– Difficult operating technique.
– Restrictive post-operative care + monitoring.
– Difficulty treating multiple recessions
Precautions and postoperative advice:
Immediately after the procedure, the patient is prescribed a painkiller. It is taken on demand as soon as the pain appears. The patient is advised to repeat this application during the day.
Antibiotic cover therapy does not appear to be necessary unless medically indicated.
Precautions during feeding are essential.
Ideally, abstain from smoking for a week.
Periodontal plastic surgery (or mucogingival surgery ):
- CONCLUSION
The demand for care has evolved, increasingly moving towards an expectation of aesthetic results. It is therefore appropriate to favor surgical techniques that allow optimal tissue integration to be obtained. Peri-implant mucogingival surgery generally meets the criteria for periodontal indications. Progress remains to be made to define its limits and indications.
Periodontal plastic surgery (or mucogingival surgery ):
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.