Attached gingiva and its significance

Attached Gingiva and Its Significance

1. Good morning… 

2. Attached Gingiva and Its Significance PRESENTATION BY: Mohamed Abdul Haleem 1st Year Perio PG KVG Dental college & Hospital, Sullia .

3. CONTENT: INTRODUCTION ANATOMY MICROSCOPIC AND MACROSCOPIC FEATURE NORMAL WIDTH OF ATTACHED GINGIVA MEASUREMENT OF WIDTH OF ATTACHED GINGIVA INADEQUATE WIDTH OF ATTACHED GINGIVA INDICATION TO INCREASE WIDTH OF ATTACHED GINGIVA KERATINIZED ATTACHED GINGIVA AROUND IMPLANTS CLINICAL SIGNIFICANCE OF ATTACHED GINGIVA AROUND IMPLANTS KERATINIZED GINGIVA WIDTH ALTERATION DURING ORTHODONTIC TREATMENT METHODS OF MEASURING THICKNESS OF ATTACHED GINGIVA CLINICAL IMPLICATION OF THICKNESS OF ATTACHED GINGIVA METHOD OF INCREASING THE WIDTH OF ATTACHED GINGIVA (GINGIVAL AUGMENTATION) REPOSITIONING THE ATTACHED GINGIVA TISSUE BARRIER CONCEPT GENERAL PRINCIPLES FOR MUCOGINGIVAL SURGERY PERIODONTAL PLASTIC SURGERY CONCLUSION REFERENCES

4. INTRODUCTION O rban and sicher - oral cavity is lined by three different kind of mucosa . Masticatory mucosa - hard palate and gingiva of alveolar process Lining mucosa - lips , cheeks and vestibular fornix Specialized mucosa covering the dorsum of tongue.

5. Gingiva is the part of the oral mucosa that covers the alveolar processes of the jaws and surrounds the necks of the teeth - Carranza 11th ed The fibrous investing tissue, covered by keratinized epithelium, which immediately surrounds a tooth and is contiguous with its periodontal ligament and with the mucosal tissues of the mouth. - A A P 1992 GINGIVA Anatomically gingiva is divided into: Free Attached and Interdental gingiva .

6. Attached gingiva is a part of keratinized gingiva which aids in Increase resistance to external injury and contribute in stabilization of gingival margin. Against frictional forces. Dissipating physiological forces exerted by the muscular fibers of the alveolar mucosa on the gingival tissues .

7. For many years the presence of an “adequate” zone of gingiva was considered critical for the maintenance of marginal tissue health & for the prevention of continuous loss of connective tissue attachment. In the early 1980s, Wennstrom et al . * conducted a series of well-designed experiments to prove that the attached gingiva and its width, have little role in maintaining periodontal health. 4-6 Successive studies went on to prove that it is not the width but the volume of attached gingiva that is critical around restored or orthodontically moved teeth. * 1. Wennstrom J.L. Lack of association between width of attached gingiva and development of soft tissue recession: A 5 year longitudinal study. J Clin Periodontol 1987;14: 181-184 2. Wennstrom J.L. Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in monkeys. Journal of Clinical Periodontology 1987; 14:121–9.

8. G lossary of periodontal term (1972 ) - Attached gingiva is that portion of gingiva that extends from the base of gingival crevice to mucogingival junction. It is firm, resilient and tightly bound to underlying periosteum, tooth of alveolar bone through connective tissue . Orban (1948 ) - first to describe attached gingiva, he divided gingiva into free and attached gingiva demarcated by free gingival groove ( FGG). A ccording to him, FGG is at appropriate level of the bottom of gingival sulcus.

9. Ainamo * and loe (1966 ) - published a study to show that FGG was present only in one-third of cases examined so it was unreasonable to assume that FGG represent the dividing line between free gingiva and attached gingiva. They suggested a better parameter “ an imaginary horizontal plane which can be drawn from the bottom of sulcus to surface of gingiva ”. 3. Ainamo J, Loe H: Anatomical characteristics of gingiva. A Clinical and microscopic study of the free and attached Gingiva. J Periodontol 1996; 37:5. Imaginary Horizontal Line

10. Facial aspects of attached gingiva extend to relatively loose and movable alveolar mucosa is demarcated by mucogingival junction. On the lingual aspect of mandible, the attached gingiva terminates at the junction of lingual alveolar mucosa, which is continuous with mucous membrane lining the floor of the mouth. The palatal surface of gingiva in maxilla blends imperceptibly with firm and resilient palatal mucosa.

11. MICROSCOPIC AND MACROSCOPIC FEATURE Histologically, the attached gingiva is better suited than non-keratinized mucosa to withstand mechanical irritations. The epithelium of attached gingiva is keratinized and has thin, prominent epithelial ridges. The connective tissue contains no elastic fibers. These characteristics are exactly the opposite of the histology of alveolar mucosa.

12. Attached gingiva is lined by four layers: 1 . Stratum Basale . 2 . Stratum spinosum . 3 . Stratum granulosm 4 . Stratum corneum .

13. Connective tissue of gingiva, also known as lamina propria and it consists of : Papillary layers subjacent to epithelium consisting of papillary projection between epithelial rete pegs . Reticular layers contiguous with periosteum of alveolar bone . P ink color of attached gingiva is governed by factor like thickness of epithelium, vascular supply and degree of keratinization and presence of pigmentation.

14. Feature which are specific to attached gingiva are : Deep rete pegs . Thick lamina propria . Abundant collagen with no elastic fibers. Indistinct sub mucosa . Attached gingiva is tough, inflexible and resistant to abrasion. Collagenous nature of connective tissue and its adherence to underlying muco-periosteum determine the firmness of attached gingiva . Thick network of closely packed collagen fibers resist the loading * . Thus attached gingiva can bear the compressive and shear forces . 4 . Bartold PM, Narayanan AS: biology of periodontal connective tissue. Chigao quintessence 1998.

15. Attached gingiva presents a surface texture similar to orange peel which is referred as a stippled . It varies among different individual and different areas of mouth. It is less prominent on the lingual surface then on the facial surface. It is absent in infancy and appear around 5 year of age. It is a form of adaptive specialization. It is produced by elevation and depression in surface of gingival tissue. Elongated papilla provides good mechanical attachment and prevents epithelium being striped under shear forces .

16. NORMAL WIDTH OF ATTACHED GINGIVA It is the distance between mucogingival junction and projection on external surface of bottom of sulcus . Width: * It is greater in incisor region. 3.5-4.5 mm in maxilla anterior . 3.3-3.9 mm in mandible anterior. It is narrower in posterior tooth region: 1.9mm in maxilla premolar 1.8 mm in mandible premolar Width of attached gingiva is minimal in newly erupted permanent teeth and increase with permanent teeth eruption. Ainamo et al. Anatomical Characteristics of Gingiva A Clinical and Microscopic Study of the Free and Attached Gingiva . J Periodontol 1966; 37:5

17. Bower * - measured the width of facial attached gingiva in both primary and permanent dentition. The width of gingiva varies from 1-9mm, being greatest at the incisor region especially in the lateral incisor and smallest in the canine and first premolar region. 5. Bowers. G, M. A study of the width of attached gingiva. Journal of Periodontology ,1963; 47:412-414

18. The first and second molar demonstrated the greatest width (4.7mm) and decrease at premolar and third molar sites. The incisor and canine demonstrated the smallest width (1.9mm ). With the progression from primary to permanent dentition the width of attached gingiva is decreased . 6. Voigt JP, Goran ML, Flesher RM. The width of lingual mandibular attached gingiva. J periodontol . 1978; 49:77–80. Voigt * et.al - measured the width of attached gingiva in clinically normal subjects.

19. Ainamo * et.al - in different studies said that, mucogingival junction remains stationary throughout life and changes in width of attached gingiva are caused by modification in position of coronal gingival. The width of attached gingiva increases with age and in supra-erupted teeth. * Maze land et.al - said that, width depends on height of alveolar process and vertical dimension of face . 7. Ainamo A: Influence of age on the location of the maxillary Mucogingival Junction. J Periodont Res 1978; 13:189. 8. Ainamo A, Ainamo J: The width of attached gingiva on Supraerupted teeth. J Periodont Res 1978; 13:194. 9. Ainamo j, talari A: the increase with age of the width of attached ginigva.j periodontal Res1976; 11:182.

20. Andin- sobocki * and bodin - in a series of studies over 2 year - used longitudinal observational to confirm the pattern of Facial keratinized tissue in children . Both primary and permanent teeth demonstrated an increase in facial keratinized tissue as the age advances. The increase of gingival widths was greatest for sites with the smallest baseline width of attached gingiva , and smallest for sites with the greatest baseline width. Zone of attached gingiva was narrower on facially positioned teeth then on lingually positioned teeth or well-aligned. 10. Anna Andlin-Sobocki , Changes of facial gingival dimensions in children A 2-year longitudinal study. Journal of Clinical Periodontology March 1993; 20(3):212–218.

21. MEASUREMENT OF WIDTH OF ATTACHED GINGIVA HALL * said that the width of attached gingiva is determined by subtracting the sulcus or pocket depth from total width of gingiva. 11. Hall WB. Can attached gingiva be increased nonsurgically ? Quintessence Int , 1982; 4: 455-462, Methods to determine mucogingival junction: 1. Visual method. 2. Functional method. 3. Visual methods after histochemistry staining .

22. I. Mucogingival junction assessed as a scalloped line separating attached gingiva from the alveolar mucosa. II. Assessed as a borderline between movable and immovable tissue. Tissue mobility is assessed by running a horizontally positioned probe from the vestibule toward the gingival margin using light force. III. Assessed visually after staining the mucogingival junction with iodine solution. Attached Gingiva – Keratinized – No glycogen in the superficial layer – Iodine Reactive Negative

23. If Mucogingival junction is distinct this is done by stretching the lip or cheek to demarcate Mucogingival junction while pocket is being probed. If Mucogingival junction is indistinct its position can be gauged by placing a probe horizontally flat against the mucosal surface and sliding it coronally .

24. INADEQUATE WIDTH OF ATTACHED GINGIVA Friedman * - Said that ‘‘ inadequate’’ zone of gingiva would facilitate Subgingival plaque Formation because of improper pocket closure resulting from the movability of the Marginal tissue. The amount of attached gingiva is generally considered to be insufficient when stretching of the lips or cheeks induce movement of free gingival margin. 12. Friedman M.T. Barber PM, Mordan NJ, Newman HN. The ‘‘plaque-free zone’’In health and disease: a scanning electron microscope study. J Periodontol . 1992; 63:890–896

25. Some people are born without sufficient attached gingiva, which results in muscles of alveolar mucosa to pull the gingiva down - Gingival recession as well as bone loss is seen. Abnormal free attachment, which exaggerates the pull on gingival margin. Deep pockets that reaches the level of mucogingival junction. Vigorous brushing in people with naturally thin tissue or when the tissues have been stretched during orthodontic treatment. It may be due to:

26. Lang * and loe - Reported a study on the relationship between the gingival width and inflammation , in an effort to determine the adequate amount. 13. Lang, N.P. & Loe , H. 1972. The relationship between the width of keratinized Gingiva and gingival health./, Periodontol.43: 623-627. In 100% of teeth with less than 2mm of keratinized tissue, inflammation and exudates was present. 76% of cases with greater than 2mm of keratinized tissue there was no exudates and was considered as clinically healthy. They concluded that 2mm of keratinized gingiva, with less than 1mm of attached gingiva is adequate to maintain gingival health.

27. Hall * mentioned few critical factors to be considered in determination of adequate attached gingiva. 14. Hall W.B. Present status of soft tissue grafting. J Periodontol 1977;48:587–97. Patients age, Level of oral hygiene practice, Teeth involved any – Tooth Malposition , Existing recession with esthetics or sensitivity problem, Patients’ dental needs – Dehiscence .

28. An adequate band of attached gingiva could be defined as that amount which is sufficient to prevent recession in opinion of individual practioners. * Thus No minimum width of attached gingiva has been established as standard necessary for gingival health. Miyasato * et al in his study concluded that there is no relationship between inflammation and amount of attached gingiva whether or not plaque is present. De tray and bernimoulin - Adequacy of attached gingiva cannot be determined by measurement of its width alone. 15. Ericsson I, Lindhe J. Recession in sites with inadequate width of the keratinized gingiva. An experimental study in the dog. Journal of Clinical Periodontology 1984; 11:95–103. 16. Miyasato M, Crigger M, Egelberg J, Gingival condition in areas of minimal and appreciable width of keratinized gingival. J Clin Periodontol . Aug 1977; 4(3):200-9.

29. INDICATION TO INCREASE WIDTH OF ATTACHED GINGIVA Patient experiencing discomfort during tooth brushing and chewing – Deep periodontal Pockets. In cases where orthodontic treatment planned and final position is expected to result in recession. To improve aesthetic – T he coverage of denuded root surface for aesthetic which increase the attached gingiva. For teeth that serve as an abutment for fixed or removable partial denture, as well area in relation to denture.

30. KERATINIZED ATTACHED GINGIVA AROUND IMPLANTS Absence of keratinized mucosa increases the suscipility of peri -implant lesions and plaque induced destruction. Keratinized gingiva around implant has more hemidesmosomes . Orientation of collagen fiber in the connective tissue zone of an implant often appear perpendicular to implant surface, but in mobile non keratinized tissue these fiber run parallel to surface of the implant. * 17. James RA, Schultz RL: Hemidesmosome and the adhesion of junctional epithelial cells to metal implants a preliminary report, J Oral Implantology; 1974; 4:294.

31. Schrodder * et al - mobile mucosa may disrupt the implant epithelial attachment zone and contribute to an increased risk of inflammation from plaque. keratinized non mobile tissue and keratinized mobile tissue are the two type of mucosa that may be found around implants . Hygiene aids are more comfortable to use within the keratinized tissue as it’s more resistant to abrasion. Mehdi Adibrad * et al said that there is a significant influence of width of keratinized mucosa on health of the peri -implant tissues. 18. Schroeder, H.E. & Listgarten , M.A. (1997). The gingival tissues: the architecture of Periodontal protection. Periodontology 2000; 13: 91–120. 19. Mehdi Adibrad , Mohammad Shahabu , MahastiSahabi , significance of the Width of Keratinized mucosa on the health status of the supporting tissue Around implants Supporting overdentures journal of Oral Implantology. 2009; 35(5)

32. The absence of adequate keratinized mucosa around implants supporting over dentures was associated with higher plaque accumulation, gingival inflammation, bleeding on probing, and mucosal recession. Listgartan and Schroeder - it is preferable to locate the implants in masticatory mucosa (Keratinized Mucosa) - Hence if there is inadequate gingiva present it is better to augment the gingiva before placement of fixture. 20. AdellR , LekholmU , RocklerB , Branemark P-I, Lindhe J, Eriksson B, Sbordone L. Marginal tissue recession at osseointegrated titanium fixture (I).A 3-year longitudinal prospective study. Int J oral maxillofacial surgery.1986; 15: 53-61. 21. Meffert RM, Langer B, Fritz ME: Dental implant: a review, J Periodontol.1992; 63: 859-870.

33. Adell * et al – Attached mucosa is necessary to prevent movement of mucosa around an exposed cover screw from inflecting trauma upon to marginal soft tissue. Meffert * et al. prefer to obtain keratinized tissue before implant placement. 20. AdellR , LekholmU , RocklerB , Branemark P-I, Lindhe J, Eriksson B, Sbordone L. Marginal tissue recession at osseointegrated titanium fixture (I).A 3-year longitudinal prospective study. Int J oral maxillofacial surgery.1986; 15: 53-61. 21. Meffert RM, Langer B, Fritz ME: Dental implant: a review, J Periodontol.1992; 63: 859-870.

34. CLINICAL SIGNIFICANCE OF ATTACHED GINGIVA AROUND IMPLANTS Prevent spread of inflammation. Prevents recession of marginal tissue. Provides tight collar around implants. Enable patients to maintain good oral hygiene.

35. METHODS OF MEASURING THICKNESS OF ATTACHED GINGIVA Gosalind * et al – Average thickness of attached gingiva is 1.25mm. Earlier method of measuring the thickness of attached gingiva includes traumatic technique like probing and injection needles. Now a day’s new methods include measuring atraumatically with the help of newer device called “ KRUPP SDM ”. 23. Gosalind GD, Robertson PB, Mahan C J, Morrison WW, Olson JV. Thickness Of facial ginigva JP. 1977; 48(12):768-71.

36. This device uses pulse echo principle with aids of pulse generator and measurement frequency of 5MHz, a piezoelectric crystal is allowed to oscillate. Ultrasonic pulses are transmitted through the sound permeable gingiva . On reaching bone or teeth surface, it is reflected. A transducer probe of 4mm diameter moistened with saliva is applied to measure site with slight pressure to produce acoustic coupling. By timing received echo with respect to transmission of pulse, thickness is digitally displayed.

37. Eager divided attached gingiva based on periodontal type: Shallow thin gingiva with slender crown formation. Wide thick gingiva with quadrant crown formation. Unknown combination Shallow, Thin Wide, Thick Combination

38. KERATINIZED GINGIVA WIDTH ALTERATION DURING ORTHODONTIC TREATMENT A Dannan * et al conducted a study to evaluate changes of keratinized gingiva width of frontal teeth during the phase of orthodontic alignment and leveling. 10 patients having front teeth crowding (120 teeth divided into 20 groups) were recruited in the study. Orthodontic alignment and leveling movements were initiated. Periodontal assessment was achieved including plaque index, probing depth, gingival index and papillary bleeding index. * A Dannan , M Darwish , M Sawan . Keratinized Gingiva Width Alteration during Orthodontic Alignment and Leveling Phase; a Preliminary Investigation. The Internet Journal of Dental Science Volume 7 Number 2

39. The width of keratinized gingiva was measured at every tooth in every group and expressed as the average of keratinized gingiva width ( aKGW ) . All clinical parameters and aKGW were assessed at baseline, at 1 month, at 3 months and at 6 months. No statistically significant changes were observed in the scores of periodontal indices and aKGW records during the whole period of observation (P>0.05). Conclusion – Orthodontic tooth alignment and leveling do not lead to significant changes in the width of keratinized gingiva when adequate plaque control is maintained.

40. CLINICAL IMPLICATION OF THICKNESS OF ATTACHED GINGIVA Gingiva thickness is genetically determined and associated with tooth form. Therefore surrounding soft tissue should carefully be considered when tooth form or size has to be altered. The successful clinical outcome of both regenerative and periodontal surgical procedures, highly rely on the thickness of attached gingiva covering it. Claffey * et al – In cases of thin gingiva, there is increased amount of recession following non-surgical periodontal treatment. 24. Claffey N, Shanley D, Relationship of gingival thickness and bleeding to loss Of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Periodontal 1986;13: 654-657

41. METHOD OF INCREASING THE WIDTH OF ATTACHED GINGIVA The earliest of these techniques are the vestibular extension operations 1. Denudation techniques. ( Ochsenbein 1960, Corn 1962, Wilderman 196425) - Removal of all soft tissue within an area extending from the gingival margin to a level apical to the mucogingival junction leaving the alveolar bone completely exposed. 2. Periosteal retention procedure or Split flap procedure ( Staffileno et al. 1962, 1966, Wilderman 1963, Pfeifer 1965) 3. Free grafts have been used for gingival augmentation (Haggerty 196626, Nabers 1966, Sullivan & Atkins 1968, Hawley & Staffileno 1970, Edel 1974).

42. The early concept was that attached gingiva is important to dissipate the force of muscle pull and unattached mucosa due to its mobility collects more plaque. Friedman * – Surgical technique to provide a functionally adequate zone of keratinized attached gingiva is known as mucogingival surgeries . The apically positioned flap, free gingival graft, and Sub epithelial connective tissue graft are the most common surgical procedures used for augmenting the zone of attached gingiva effectively and predictably. 27. Freidman, N.mucogingival surgery .The Apically repositioned flap. Journal of periodontology 33,328-340.

43. These procedure may be combined with other procedure to obtain a healthy periodontal complex – A complex capable of withstanding the stress of mastication, tooth brushing, trauma from foreign bodies, tooth preparation associated with a crown and bridge, Subgingival restoration, orthodontic treatments, inflammation and frenum pull. * 28. Stetler K, Bissada NF: significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restoration, J Periodonto , l1987; 58:696-700, PRF GBR Bone Graft Collagen Membranes

44. TISSUE BARRIER CONCEPT Goldman * and Cohen outlined a “tissue barrier” concept for mucogingival surgery. They postulated that a dense Collagenous band of connective tissue retard or obstruct the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa. They recommended increasing the zone of keratinized tissue to achieve an adequate tissue barrier 29. Goldman H. Periodontal therapy. 6th ed. St. Louis: CVMosby ; 1979; 5.

45. GENERAL PRINCIPLES FOR MUCOGINGIVAL SURGERY * Existing keratinized gingiva should always be maintained. Exposing bone to increasing the zone of keratinized gingiva is contraindicated (wilderman1964). When an adequate zone of keratinized gingiva exists, vestibular depth is not a factor. 30. Carranza Jr FA, Carraro JJ. Mucogingival techniques in periodontal surgery. Journal of Periodontology 1970; 41:294–9.

46. PERIODONTAL PLASTIC SURGERY Soft Tissue Grafting Indications and Procedures

47. COMMON QUESTIONS ASKED BY PATIENTS: When is gingival grafting needed and when is it not? Why do I need it? What happens if I don’t do it? Does it hurt? What is the recovery time? Does it work? Does it have to be redone? How much does it cost?

48. DEFINITIONS Attached Gingiva – The portion of the gingiva that is firm, dense, stippled and tightly bound to the underlying periosteum , tooth, and bone. Free Gingiva – That part of the gingiva that surrounds the tooth and is not directly attached to the tooth.

49. Mucogingival Junction – the area of union of the gingiva and alveolar mucosa Alveolar Mucosa – Loosely attached mucosa covering the basal part of the alveolar process and continuing into the vestibular fornix and the floor of the mouth

50. Mucogingival Defect – A departure from the normal dimension and morphology of the relationship between the gingiva and the alveolar mucosa

51. Free Gingival Graft (FGG) - A soft tissue graft that is completely detached from one site and transferred to a remote site. No connection with the donor site is maintained. Subepithelial Connective Tissue Graft (CTG) - A detached connective tissue graft that is placed beneath a partial thickness flap. This variation of the free gingival graft provides the tissue graft with a nutrient supply on two surfaces.

52. HISTORY OF PERIODONTAL PLASTIC SURGERY 1930’s – Frenectomies and vestibuloplasties 1948 – First Gingivoplasties 1956 – Grupe and Warren publish Laterally Positioned Flap 1963 – Bjorn publishes the Free Gingival Graft 1982 – P.D. Miller introduces the FGG for root coverage. Fernandez does first CT graft 1989 – AAP renames Mucogingival Surgery to Periodontal Plastic Surgery

53. INDICATIONS FOR PERIO PLASTIC SURGERY Gingival Augmentation Free Gingival Graft Connective Tissue Graft Root Coverage Coronally positioned flap Semilunar flap Laterally positioned flap Double papilla flap Free Gingival Graft Connective Tissue Graft Guided Tissue Regeneration using allograft

54. Grafting Decision Tree Leong and Wang. IJPRD 2011; 31 (3) 307 - 313 APF – Aically Positioned Flap CAF – Coronally Advanced Flap ADM – Acellular Dermal Matrix GTRC – Guided Tissue Root Coverage

55. HOW MUCH KERATINIZED GINGIVA IS NEEDED ? Bowers 1963 – felt that gingival health could be maintained with a narrow zoned of KG (<1mm) but some is required for healing. Lang & Loe 1968 – suggested 2mm Maynard and Wilson 1979 – 5mm of KG with 3mm attached gingiva when subgingival restorations are planned Kennedy 1985 – over a 6 year period, in patients with inconsistent OH saw recession with thin tissue. Bottom Line : some attached gingiva is necessary for health, but patients with good OH can maintain thin AG.

56. WHEN IS GRAFTING NEEDED? When there is, Recession progressing. Tooth planned for orthodontic care or prosthetic treatment. Root sensitivity. Difficulty cleaning the root surface by the patient. An esthetic concern.

57. FREE GINGIVAL AUTOGRAFTS Indications To increase keratinized tissue around teeth, implants or crowns To increase keratinized tissue under removable prostheses To increase vestibular depth Disadvantages Difficult to achieve root coverage High esthetic demand Large, uncomfortable donor site Graft site, slow uncomfortable healing

58. Free Gingival Autografts Classic “Gum Graft” Will increase keratinized gingiva Results in “Tire Patch” look

59. Free Gingival Graft Pre-op

60. Free Gingival Graft Recipient Site Donor Site

61. Free Gingival Graft Before Long-term follow-up

62. MILLER CLASSIFICATION OF RECESSION Class I . Recession that has not extended to MGJ. No bone loss Class II . Recession to or beyond the MGJ. No bone loss Class III . Recession to or beyond MGJ. Bone loss with or without tooth malposition . Class IV . Recession beyond MGJ. Bone loss to the base of recession defect with tooth malposition .

63. CAUSES AND PREDISPOSING FACTORS IN GINGIVAL RECESSION Predisposing Factors: Minimal attached gingiva /thin tissue biotype Frenum pull / shallow vestibule Tooth malposition Precipitating Factors: Inflammation related to plaque Restorations adjacent to thin tissue Occlusal Trauma including orthodontic treatment Bone loss at an adjacent site

64. CONNECTIVE TISSUE GRAFT Advantages Very predictable for root coverage Smaller donor site (than FGG) Smaller recipient site (than FGG) Less soreness overall (than FGG) Uses patient’s own tissue Excellent esthetics Can cover multiple, large recessions even on teeth with a previous gingival restorations.

65. CONNECTIVE TISSUE GRAFTS Disadvantages Two surgical sites Technique sensitive Bleeding from palate (potential)

66. Connective Tissue Grafts Surgical technique Root preparation Thorough root planing of exposed root to remove infected cementum and affected dentin Etch root surface with tetracycline (pH 2.0) Exposes collagen tufts to promote fibroblast adhesion

67. Connective Tissue Graft Incision design (tunnel technique) Create “pouch” using full/split thickness incision between gingiva and bone/root Maintain papilla for bilateral blood supply Extend incision to adjacent teeth Undermine flap

68. Connective Tissue Graft Surgical Technique Donor site incision ( Buser ) First palatal incision perpendicular to long axis of teeth and approximately 2 to 3 mm apical to the gingival margin.

69. Connective Tissue Graft Surgical Technique Donor site incision ( Buser ) Second palatal incision parallel to long axis of teeth and approximately 1 to 2 mm apical to first incision. More apical the second incison , more thicker the donar tissue will be. Height of the palate determines the extent of the palatal incision.

70. Connective Tissue Graft Donor Site Harvest Tissue Suture Palate

71. Connective Tissue Graft Recipient site Insert Graft Into Tunnel Suture using interrupted and sling sutures

72. Connective Tissue Graft Before After

73. Connective Tissue Graft Pre-op Post-op Occlusal Trauma

74. Connective Tissue Grafts Miller Class IV with supra-eruption of central incisor Only minimal root coverage was possible

75. Connective Tissue Grafts Before 3 years post-op

76. Does it HURT? The common perception is that Connective Tissue Grafting is VERY PAINFUL!! This is often the patient’s perception

77. Does it HURT? Reality In 20 years of performing CT grafts, very few patients ever complain about significant pain afterwards Most are pleasantly surprised at how little pain they had Very little post-op bleeding, swelling or bruising Of course, everyone’s pain threshold is different…

78. WHAT IS THE RECOVERY TIME? Recovery times vary from individual to individual Post-op instructions include: Soft foods for a week Avoid chewing in the donor or recipient sites if possible for the first week Bleeding from the palate is possible for the first 24 hours and sometimes longer Don’t brush the donor site for 1 week; the recipient site for 3 weeks. Patient should use Chlorhexidine mouthwash in the meantime Ibuprofen 800mg 3/day for 2 – 3 days

79. WHAT IS THE RECOVERY TIME? Patients may report of some soreness during the first week, but that will subside eventually. Some swelling of the recipient site is normal and occasionally some bruising can be seen. Resorbable sutures - Sutures resorb in the palate in 2 – 3 days and in about 1 week in the recipient site. Most people resume normal activities either the next day or two days after. In smokers healing is more slow and results are less predictable.

80. CONCLUSIONS Mucogingival defects are very common across all age groups and both genders Mucogingival defects can be either congenital or acquired with both predisposing and precipitating factors Periodontal Plastic Surgery can be used to correct mucogingival defects via a variety of methods and techniques Indications for Periodontal Plastic Surgery can vary depending on rate of progression or the impact of local factors

81. CONCLUSION The adequate width attached gingiva should cover the essential component for Maintaining Healthy Periodontium . Adequate keratinized gingiva provides a firm and stable base for maintaining good oral hygiene, restorative and esthetic procedure. Restoring dentist should be aware of the biology of keratinized Gingiva and methods for increasing the attached gingiva for a successful treatment Outcome.

82. Any Questions?

83. Thank You…

84. REFERENCES 1. Wennstrom J.L. Lack of association between width of attached gingiva and development of soft tissue recession: A 5 year longitudinal study. J Clin Periodontol 1987;14: 181-184,. 2. Wennstrom J.L. Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in monkeys. Journal of Clinical Periodontology 1987; 14:121–9. 3. Ainamo J, Loe H: Anatomical characteristics of gingiva. A Clinical and microscopic study of the free and attached Gingiva. J Periodontol 1996; 37:5. 4. Bartold PM, Narayanan AS: biology of periodontal connective tissue. Chigao quintessence 1998. 5. Bowers. G, M. A study of the width of attached gingiva. Journal of Periodontology ,1963; 47:412-414 6. Voigt JP, Goran ML, Flesher RM. The width of lingual mandibular attached gingiva. J periodontol . 1978; 49:77–80. 7. Ainamo A: Influence of age on the location of the maxillary Mucogingival Junction. J Periodont Res 1978; 13:189. 8. Ainamo A, Ainamo J: The width of attached gingiva on Supraerupted teeth. J Periodont Res 1978; 13:194. 9. Ainamo j, talari A: the increase with age of the width of attached ginigva.j periodontal Res1976; 11:182. 10. Anna Andlin-Sobocki , Changes of facial gingival dimensions in children A 2-year longitudinal study. Journal of Clinical Periodontology March 1993; 20(3):212–218,

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