Diagnosis and Treatment of Mucogingival Defects

Charlotte Dental Hygiene
Study Club
Inaugural Meeting
October 9, 2008
CharlottePerio
Rubins, Tolmie,
Corsig, and Kerr
TOLMIE & RASENBERGER
Tolmie, Rasenberger,
and van Kesteren
Diagnosis and Treatment of
Mucogingival Defects
Eric Kerr D.D.S., M.S.
Chris van Kesteren D.D.S., M.S.
October 9, 2008
Mucogingival Deformities
• Around Teeth
– Gingival / soft tissue recession
– Lack of keratinized/attached gingiva
– Decreased vestibular depth
– Aberrant frenum / muscle position
– Gingival excess
Annals of Periodontology 1999
Recession
Recession / Inadequate
Attached Gingiva
Aberrant frenum
Lack of Vestibular Depth
Definitions
• Gingival Recession
• Keratinized Gingiva
• Mucogingival Junction
• Attached Gingiva
• Hidden Recession
• Alveolar Mucosa
Problems?
Etiology
• Periodontal Disease
• Trauma
– Brushing and flossing
– Habits
– Iatrogenic
Contributing Factors
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Genetics
Biotype – Thin or thick tissues
Tooth Positioning
Frenum Pull
Shallow Vestibule
Oral hygiene
Smoking
Primary Contributing Factor
• Thin periodontium- strongest association
with soft tissue recession
• Investing bone is thin or absent
• Soft tissue is thin
– Main cause: prominent roots
Bannister 2006
Thin Periodontium
• Locations:
– Max / Mand Incisors, Canines, Premolars
– MB root of the Max 1st molars
• Orthodontic Treatment
– Mand Anteriors
• Crowding / Malocclusion
Bannister 2006
Rationale for Treatment
• Esthetics
• Sensitivity
• Progressive attachment loss
Indications for Treatment
• Compromised Oral Hygiene
• Relieve Aberrant Frenum Pull
• Vestibular Extension
• Root Coverage
Indications for Treatment
• Pre-prosthetic
– Provide attached gingiva for subgingival
restorations or RPD clasps
– Correct soft tissue ridge defects
– Augment dental implant sites
• Pre-orthodontic
– Augment sites of thin tissue
– Crown uncovering
Treatment Modalities
• Grafting
– Connective tissue
– Free gingival graft
– Allograft
• Frenectomy
• Combination procedures
Connective Tissue Graft
• Indications
– Esthetics
– Sensitivity
– Root Coverage
• Advantages
– Better color match
– Less painful donor site
– Predictable root coverage
• Disadvantages
– Two surgical sites
– Adequate donor tissues
– Technically more challenging
Free Gingival Graft
• Indications
– Minimal Keratinized Tissue
– Frenum Pull
– Shallow vestibule
• Advantages
– Less technically demanding
– Combined procedure
– Creeping attachment
• Disadvantages
– Color match
– Two surgical sites
– Less predictable root coverage
– Patient discomfort
Allograft / “Alloderm”
• Indications
– Multiple areas of recession
– Inadequate donor tissue
– Advantages
– Easier suturing
– No donor site needed
• Disadvantages
– Long-term stability?
– Technique sensitive
– Slower healing (2-3 weeks)
– Complete coverage essential
– Lack of keratinized tissue
– Wound healing like scar tissue
Videos
Pre-op discussion
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Envelope example
Stent
Growth factors
Pain - Pizza burn (CT vs FGG)
Ibuprofen and Tylenol (RX if you need it)
Keratinized tissue vs mucosal tissue
If you had enough attached tissue, I
wouldn’t recommend a graft
Wound Healing
• Vascular wound healing 1st 10 days
• Subtle changes over 12 months
– creeping attachment
• Post op instructions
– Gentle rinsing twice daily 1-2 weeks
– Follow-up at 1 week and 1 month
– At 2 weeks, ultra-soft toothbrush is introduced
with coronally directed roll technique
Factors Affecting Surgical Outcome
• Pre-operative bone levels
• Oral hygiene
• Blood supply
• Stabilization
• Smoking
Surgeries
• Key in on:
– Recession Classification
– Factors causing contributing to the recession
• Type of existing periodontium: Thin / Thick
– Surgical Location
• Localized / Generalized
– Surgical Outcomes Desires
• Attached gingiva, root coverage, etc.
Cases
Mrs. R
Connective Tissue Graft
Incisions
Site Preparation
Bone Loss
Closure
2 Week Post-op
2 Week Post-op
1 Month Post-op
1 Month Post-op
Pre-op
Post-op
Mrs. B
Free Gingival Graft
Site Preparation
Free Gingival Graft
Goals: Increase band of attached / keratinized tissue
Minimal root coverage due to tooth prominence
Improve vestibular depth
Post-op
Post-op
Pre-op and Post-op
Mr. W
Connective Tissue Graft – Tunnel Preparation
Tunnel Prep
Pre-op
Post-op
Mr. P
Allograft
Graft Adaptation
Sutures
Pre-op
Post-op
Mr. V
Connective Tissue Graft
Graft Sutured
Flap Advancement
Post-op
Mr. H
Miss L
Frenectomy
Pre-op and Post-op
Miss R
Frenectomy / Double Pedicle Flap
Frenectomy
Double Pedicle Flaps
3 month post op
Pre-op
Post-op
Ms. K
Connective Tissue Graft
Split Thickness Flap
Donor Site
Connective Tissue Harvest
Sutures
1 Week Post-op
Pre-op
Post-op
Ms. I
Connective Tissue Graft and Dental Implant
4 Months Post op
Pre-op
Post-op
Mucogingival Deformities
• Around Teeth
– Gingival / soft tissue recession
– Lack of keratinized/attached gingiva
– Decreased vestibular depth
– Aberrant frenum / muscle position
– Gingival excess
Annals of Periodontology 1999
Questions?
Thank You
Extra stuff
Pre and Post-Op
Pre-op and Post-Op
Pre-op and Post-Op
Recession?
What is the Patient’s Chief Complaint?
Mucogingival Deformities
• Edentulous Ridges
– Vertical and/or horizontal ridge deficiency
– Lack of gingiva / keratinized tissue
– Gingival / soft tissue enlargement
– Aberrant frenum / muscle position
– Decreased vestibular depth
Annals of Periodontology 1999
Classification of Gingival
Recession
• Class I
• Class II
• Class III
• Class IV
PD Miller 1985
• Class I:
– Recession short of the MGJ.
– No interdental bone or tissue loss.
100% root coverage possible
PD Miller 1985
• Class II:
– Recession to or past MGJ.
– No loss of bone or interdental tissue.
100% root coverage possible
PD Miller 1985
• Class III:
– Recession to or beyond the MGJ.
– Loss of interdental bone or tissue, and / or
tooth malpositioning
Only partial root coverage possible due to loss
of interdental bone and tissue
PD Miller 1985
• Class IV:
– Recession to or beyond the MGJ.
– Loss of interdental bone extends apically to
the extent of marginal soft tissue recession.
No root coverage due to severe loss of
interdental bone and tissue
PD Miller 1985
Mucogingival Deformities
• Around Teeth
– Gingival/soft tissue recession
– Lack of keratinized gingiva
– Decreased vestibular depth
– Aberrant frenum/muscle position
– Gingival excess
Definitions
Gingival Recession
Keratinized Gingiva
Hidden Recession
Attached Gingiva
Mucogingival Junction
Other Dental Treatment
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Soft Tissue Ridge Defects
Pre-Prosthetic Augmentation
Pre-Orthodontic Augmentation
Vestibular extension
• Objectives
– Repair ridge defects
– Create or widen zone of keratinized
tissue
– Eliminate soft tissue undercuts
Considerations
• How would we classify the
recession?
• What is the expected root
coverage?
• What are some etiologic factors
contributing to the recession?
• What factors influence the
surgical outcomes?
• How will the treatment heal?
Root Coverage
• Objectives
– Increase soft tissue root coverage
– Increase soft tissue thickness
– Create symmetrical gingival contours
– Eliminate aberrant frenum pull
– Prevent further attachment loss (bone and
soft tissue)
Bannister 2006