Therapeutics for defects of the mucogingival complex

Therapeutics for defects of the mucogingival complex

The treatment of mucogingival defects is based on mucogingival surgery techniques.

2. Examination of the mucogingival complex:

 Gum size:

 Height of free gingiva, attached gingiva and keratinized tissue:

Using a graduated periodontal probe, the following distances are measured:

• Top of the gingival margin – bottom of the sulcus (or pocket) = height of free gingiva = depth of sulcus or pocket
• Top of the gingival margin-mucogingival line = height of keratinized gingiva
• Gingival margin summit-enamel-cementum junction = marginal tissue recession height.

The height of attached gingiva is equal to the subtraction of the value of the sulcus (or pocket) depth from the height of keratinized tissue.

 Gum thickness :

For Wilson and Maynard, a test for thickness assessment can consist of placing a colored periodontal probe in the sulcus; its visibility through the tissues makes the gingiva considered thin. This is the simplest and most easily implemented technique in routine clinical practice.

 Assessment of biological space:

At the periphery of the cuff preparations, probing under local anesthesia should reveal a distance equal to or greater than 2 mm between the cervical border and the top of the bony crest. A 2 mm gap means that the biological space has been respected but that the cervical border is located at the bottom of the sulcus. To ensure that the intrasulcular cervical border remains within reach of bacterial plaque control methods, it is preferable to allow a greater distance.

 Vestibular brakes:

This examination is performed by vigorous traction of the lip. The major signs are mobility and opening of the gingivodental sulcus during lip traction.

The location of the upper labial frenulum corresponds to the four anatomical situations of the classification of Placek et al.

1. Mucosal attachment: the insertion of the upper labial frenulum belongs to the alveolar mucosa and is located at the limit of the mucogingival line.
2. Gingival attachment: the lower insertions of the labial frenulum are embedded in the attached gingiva.
3. Papillary attachment: the upper frenum is inserted into the papillary gingiva. Mobilization of the lip (traction test) in this case causes a displacement of the marginal gingiva of the central incisors.
4. Interdental attachment: the upper 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 interincisal diastema.

 The lingual frenulum:

The patient should be asked to:

• Propel the tongue towards the chin;
• Place the tip of the tongue at the top of the palate.

If these two movements are impossible to perform or of very reduced amplitude, it is likely that the lingual frenulum is too short and too tight.

It will then be necessary to evaluate its insertion zone at the level of the mandibular retro-incisive lingual gingiva. The insertion can be mucosal, at the level of the mucogingival line, at the level of the attached gingiva or the free gingiva creating a traction of the sulcus.

3. Mucogingival surgery:

Mucogingival surgery is a plastic surgery that aims to correct the morphology, position and/or quality of the gingival tissue that borders the tooth; one of its indications is gingival recession.

4. Different mucogingival surgery techniques:
   1.  frenectomy/frenotomy:

Frenectomy is the complete removal of a frenulum and is different from the partial removal called frenotomy .

 Objective :

• Eliminate muscle traction transmitted via the frenulum fibers to the marginal gingiva.

 Indications:

• Hypertrophic frenulum associated with a diastema.
• Vestibular frenulum limiting hygiene maneuvers, pulling the marginal gingiva or promoting the appearance of recessions. In this case, we often observe a very low height of attached gingiva.
• Mucogingival surgery in an area with a frenulum.
• Short lingual frenulum limiting the range of movement of the tongue, hindering phonation, swallowing or maxillary or mandibular development.

Techniques:

For secondary vestibular frenulums, a simple frenotomy is often sufficient. The frenulum is incised at its tip, dissected in partial thickness, and then re-sutured apically. If this is not sufficient, the technique described for medial frenulums can be applied. In the case of a short lingual frenulum, which limits tongue mobility, frenotomy is the procedure of choice.

 Vestibular frenectomy :

1. Anesthesia by vestibular para-apical infiltrations then papillary and palatal reminders.
2. Pull the lip back so that you can clearly see the entire frenulum.
3. Make a 1mm incision on either side of the frenulum, parallel to it, along the entire height of the attached gum. The blade must be in contact with the bone.
4. In the case of interincisal diastema, extend the incisions palatal so as to encompass the retro-incisal papilla in the same way as for the aesthetic access flap.
5. Resect the frenulum thus demarcated using a rongeur. Then remove all the underlying fibers inserted into the bone and the intermaxillary suture.
6. With the blade oriented apically, incise the frenulum horizontally at the level of the mucogingival junction line. Dissect it in partial thickness in the apical direction.
7. Suture the free mucosal wound with a series of O-shaped stitches. Leave the gum wound attached raw or make a protective X-shaped stitch.

 Lingual frenotomy:

1. The main difficulty of this technique is the respect of noble structures such as arteries, nerves and salivary gland ducts present at the level of the lingual floor.
2. Anesthesia by infiltrations on either side of the frenulum and at the base of the tongue.
3. Keep the tongue firmly in traction by reclining it and visualize the ostia of the Wharton canals so as not to damage them.
4. Insert the scalpel very shallowly and make horizontal incisions from the tip of the tongue towards the base of the tongue until it regains physiological mobility. A diamond-shaped wound appears.
5. Bring the edges of the wound together in a diamond shape and suture them with O-shaped stitches.
6. Have the patient stick out their tongue to check that the frenulum is properly released.

2.  Vestibuloplasty:

 Definition :

Surgical procedure for vestibular extension.

 Indication:

Short vestibule

 Goals :

• Increase the vestibular depth to provide adequate space to increase the area of ​​attached gingiva.
• Transforming a mobile alveolar mucosa into one firmly attached to the underlying periosteum.

 Techniques:

The surgical protocol takes place in four stages:

1. Asepsis: Disinfection of the operating field
2. Local anesthesia with vasoconstrictor
3. Incision – A horizontal incision along the mucogingival line, the blade should go down to bone contact
   • A gauze compress is placed at the edge of the incision and with pressure exerted against the alveolar wall, a partial thickness flap is detached and gradually lowered towards the bottom of the vestibule.
   • The periosteum is exposed.
   • The fine muscle insertions are cut with a scalpel blade. – Rinse with physiological serum.
4. Windows
   • A curette starting from one end, removes the periosteum the width of the head of this curette (approximately 2mm)
   • Good hemostasis.
   • Surgical dressing.

4 3- the displaced flaps:

 Coronally displaced flap:

• Goals

• Covering a recession.
• Cover a membrane following a bone graft or guided tissue regeneration.
• Indications

• Miller Class 1 single or multiple recessions.
• Presence of a sufficient volume of keratinized tissue located apical to the recession.
• Keratinized tissue thickness of at least 0.8 mm.
• Technical

1. Take measurements with the periodontal probe beforehand to assess the extent of the desired movement.
2. Anesthetize.
3. Using blade 15, trace the future papillae, spaced from the top of the initial papilla by the same height as the recession to be covered.
4. Draw the discharge incisions in parallel, looking for bone contact.
5. Once the mucogingival junction line is crossed, make oblique incisions in the alveolar mucosa to increase the laxity of the flap during its movement.
6. Using a fine peeler, begin the total thickness elevation from one of the newly redesigned papillae.
7. Continue this mucoperiosteal detachment to the mucogingival junction line.
8. Once this line is reached, incise the periosteum apically and continue the partial thickness dissection in the alveolar mucosa.
9. Release all apical traction fibers using blade 15.
10. Check the passive repositioning of the flap in the desired position.
11. Gently surface the exposed cementum.
12. De-epithelialize the initial papillae using a 15 blade.
13. Begin the sutures with O-shaped stitches suspended above the contact points of the tooth.
14. Suture the parallel discharges with O-shaped stitches.

 Laterally displaced flap:

• Goals
• Covering a recession.
• Bring keratinized tissue next to a natural tooth or an implant.
• Indications
• 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.
• Technical

1. Preliminarily assess the sliding pattern with the periodontal probe.
2. Anesthetize.
3. Gently surface the root.
4. Make the incisions with blade 15 at the level of the recession
5. Intrasulcular incision which continues in an internal bevel in an angulated manner beyond the mucogingival junction line and thus delimits the proximal edge of the flap.
6. External bevel incision starting at the base of the contralateral papilla and joining the apical tip of the last incision to create a 2-3 mm wide raw zone. The triangle thus formed at the base of the recession is de-epithelialized.
7. Make the flap incisions:
   1. Scalloped horizontal incision in the gum starting from the base of the papilla of the tooth with the recession and leaving at least 2 mm of attached gum around the adjacent teeth. This incision delimits a flap one and a half times wider than the recession to be covered;
   2. Discharging incision which is made up to the mucogingival junction line and which continues with an oblique incision in the alveolar mucosa converging at the recession.
8. Elevate the flap by starting with a full-thickness undermining beginning proximal to the recession and extending across half of the flap.
9. 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.
10. With all residual tension removed, the flap is then moved passively over the area to be covered.
11. Suture the flap starting at the mesial angle, then the papillae. The mesial discharge is then sutured and finally periosteal stitches are made at the distal discharge.

4-4- Free gingival graft: Goals :

• Increase the volume of keratinized tissue.
• Stop the progression of recessions due to the action of traumatic bridles and brakes and cover them.
• Deepen a vestibule.
• Promote prosthetic and implant periodontal integration by creating an area of ​​attached keratinized gingiva capable of resisting the trauma of chewing and brushing.
• Allows the creation of primary healing sites during soft tissue surgery. The graft is then used as a biological dressing.
• Remove gum tattoos.

 Indications :

• Presence of one or more Miller class 1 or 2 recessions induced by traumatic bridles and frenulums.
• Presence of low attached gum height 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.

 Technique:

 Preparation of the recipient site:

1. Manually mobilize the cheek or lip, which facilitates visualization of the LJMG and dissection.
2. Anesthetize the site with para-apical infiltrations. The swelling then observed in the free mucosa promotes visualization of the LJMG.
3. Make an intrasulcular incision with a 15 blade in the teeth to be treated or parallel to the LJMG.
4. Continue the incision horizontally, coronal to the mucogingival junction line, tilting the scalpel blade so as to bevel the edges of the recipient bed.
5. Make two discharging incisions extending apically into the mucosa.
6. Begin the partial thickness dissection at one of the coronal angles of the flap with a 15 blade.
7. Continue the dissection apically, taking care to eliminate all fibrous and muscular tension.
8. Manually manipulate the soft tissues surrounding the site to ensure that no mobility occurs in the prepared connective tissue bed.
9. Suture the attached gingival strip of the flap, apically to the recipient bed using periosteal O-stitches. They are made with absorbable thread to avoid trauma during removal.
10. Precisely measure the dimensions of the site using a periodontal probe and make a template with the suture thread packaging cardboard to the exact dimension of the recipient bed.
11. Place a compress soaked in physiological saline on the recipient bed during the collection phase. This helps limit clot formation.

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 outlining the graft by following the edges of the template. The incision is made deep, 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 at the mesiocoronal angle. Ensure a thickness of at least 1.5 mm.
4. Hold the graft with dissecting forceps to curve it and allow control of the dissection with the 15 blade.
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 saline. Once the bleeding has decreased, place a collagen compress and then insert the palatal plate to compress it.

 Graft placement:

1. Check that the graft is perfectly adapted, making sure to place the connective tissue surface of the graft against the connective tissue bed of the recipient site.
2. At one of the coronal angles, make a first pass of the suture thread.
3. Make the first positioning stitch at O, at the angle in which the thread was initially passed. This stitch is made in a papilla.
4. Suture the graft with papillary stitches to stabilize it in the desired position.
5. Place vertical periosteal stitches at their base and suspended around the teeth to be treated. The periosteum is attached to the underlying bone, allowing the stitches to remain fixed. These vertical stitches can be single or continuous and are intended to hold the graft against the recipient bed.
6. Finally, make a vertical crossed quilted stitch, flattening the graft across its entire width.
7. Check the immobility of the graft by manipulating the surrounding soft tissues.
8. Apply compression to the site for at least 5 minutes to limit clot formation and promote revascularization.

4-4- Connective tissue graft:

 Goals

• Cover one or more root recessions.
• Thicken gum tissue next to a natural prosthetic abutment.

 Indications

Miller Class 1 Recessions.

 Technical

• Preparation of the recipient site : is done as previously described for the epithelial-connective graft
• Collection : is done as for the epithelioconnective graft except that the graft must be de-epithelialized to leave only the connective tissue which will then be sutured to the recipient site.
• Graft placement:

1. Place the graft on the site so that the thickest part covers all of the recessions. Check that it fits perfectly.
2. Suture the graft by its mesial and distal edges to the underlying periosteum so as to immobilize it on the recipient site. An absorbable suture is then used because it cannot be removed.
3. Check the passive repositioning of the flap so as to perfectly cover the connective tissue supply.
4. Make hanging stitches at the contact points at each papilla .
5. Suture the discharges with O-shaped stitches.

5. Conclusion :

The mucogingival surgery technique must be carefully chosen according to the indication and the dexterity of the practitioner.

6. Bibliographic references:

1. Bouchard Philippe, Periodontology and Implant Dentistry , Volume 1, Lavoisier, 2015.
2. Bercy, Tenenbaum, periodontology from diagnosis to practice, de boek, 2000.
3. Vigouroux F: Practical guide to periodontal surgery. Elsevier edition, Masson, 2011.
4. Wolf HF, Rateitschak EM, Rateitschak KH. Periodontology. 3rd edition. Paris: Masson; 2005.

Therapeutics for defects of the mucogingival complex

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Therapeutics for defects of the mucogingival complex