Attached Gingiva.pptx

introduction and techniques to increase width of attached gingiva with articles

1. Attached Gingiva and Techniques to Increase its Width Dr. Rinisha Sinha MDS Part II Department of Periodontology

2. Content Introduction What is Attached Gingiva? Characteristics Width of Attached Gingiva Quality of Attached Gingiva What is inadequate Attached Gingiva? Problems associated with Inadequate Attached Gingiva Indications to increase zone of attached gingiva Techniques Conclusion & References 2

3. Introduction Oral cavity is lined by three different kind of mucosa : Masticatory Mucosa – Hard palate and the gingiva of alveolar process Lining Mucosa – lips, cheek and vestibular fornix Specialized Mucosa – covering the dorsum of the tongue 3 Reference: Orban & Sicher The term Mucogingival Surgery was introduced in the periodontal literature by Friedman in 1957 and was defined as “Surgical procedures to preserve gingiva, remove aberrant frenulum or muscle attachments and increase the depth of the vestibule” Reference: Glossary of periodontal terms, 1992 Miller in 1988 suggested the term Periodontal plastic surgery to be more appropriate; defined as “Surgical procedures performed to correct or eliminate anatomic, developmental or traumatic deformities of the gingiva and alveolar mucosa” Reference: Proceedings of the World Workshop in Periodontics, 1996

4. Gingiva It is the part of the oral mucosa that covers the alveolar processes of the jaw and surrounds the neck of the teeth. The fibrous investing tissue, covered by keratinized epithelium, which immediately surrounds the tooth and is contiguous with its periodontal ligament and with the mucosal tissues of the mouth. 4 Reference: Carranza 10 th edition Reference: AAP, 1992

5. What is Attached Gingiva ??? “That portion of gingiva that extends from base of the gingival crevice to the mucogingival junction.” “It is the combination of epithelium and connective tissue defined as a portion of mucous membrane in complete post-eruptive dentition of a healthy young individual; it is attached to teeth and alveolar process.” Reference: Glossary of Periodontal terms, 1972 Reference: Schroeder, 19 “That part of gingiva that is firmly attached to the underlying tooth and bone and is stippled on its surface.” “The portion of the gingiva extending from the base of the gingival crevice to the MGJ. It is firm, dense, stippled and tightly bound down to the underlying periosteum and tooth”. Reference: Orban ; 1948 Reference: Glossary of Periodontal terms; 1977

6. Characteristics of Attached Gingiva 6

7. Facial aspect extend to relatively loose and movable alveolar mucosa; demarcated by mucogingival junction. On the lingual aspect of mandible , it terminates at the junction of lingual alveolar mucosa, which is continuous with the mucous membrane lining the floor of the mouth. The palatal surface in the maxilla blends imperceptibly with the firm and resilient palatal mucosa. It is tough, inflexible and resistant to abrasion. 7 Reference: Clinical Periodontology and Implant Dentistry – Jan Lindhe , 5th edition

8. Functions Increased resistance to external injury and contribute in stabilization of gingival margin. Aids against frictional forces. Dissipates physiological forces exerted by the muscular fibers of the alveolar mucosa on the gingival tissues. Acts as a buffer zone/neutral zone between movable and immovable zone. Provides tight collar around implants. Maintains vestibular depth. Protective against accumulation of plaque. 8 Reference: Clinical peridontology 8, 9, 1Oth edition - Carranza F.A., Michael G. Newman.

9. Microscopic and Macroscopic Features Epithelium: keratinized with thin, prominent epithelial ridges. Connective tissue: no elastic fibers. Specific features: 9 Reference: Clinical peridontology 8, 9, 1Oth edition - Carranza F.A., Michael G. Newman.

10. Width of Attached Gingiva 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 the attached gingiva that is critical around restored or orthodontically moved teeth . 10 Reference: Wennstrom J.L. Lack of association between width of the attached gingiva and development of soft tissue recession: A 5-year longitudinal study. J Clin Periodontol 1987; 14; 181-184. Reference: Wennstrom J.L, Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in monkets . Journal of Clinical Periodontology 1987; 14; 121-9. It is the distance between mucogingival junction and projection on external surface of bottom of sulcus. Reference: Ainamo J, Loe H. Anatomical characteristics of gingiva. A clinical and microscopic study of the free and attached gingiva. J Periodontol 1996; 37:5.

11. Width: Greater in incisor region – Narrower in posterior region – Minimal in newly erupted permanent teeth and increases with permanent teeth eruption. 11 Reference: Ainamo J, Loe H. Anatomical characteristics of gingiva. A clinical and microscopic study of the free and attached gingiva. J Periodontol 1996; 37:5. Width of Attached Gingiva : the distance between the mucogingival junction to projection of the external surface of the bottom of the sulcus or the periodontal pocket Reference: FiorelliniJP , Kim DM, Ishikawa SO. Thegingiva . In: Newman MG, Takei H, Klokkevold PR, Carranza FA, editors. Carranza’s Clinical Periodontology. 10th ed. Missouri: Saunders Publishers; 2006. p. 46-7. The mucogingival junction serves as an important clinical landmark in periodontal evaluation

12. Measurement of Width of Attached Gingiva The width of attached gingiva is determined by subtracting the sulcus or pocket depth from the total width of gingiva. 12 Reference: Hall WB. Can attached gingiva be increased non-surgically? Quintessence Int, 1992; 4: 455 – 462. Reference: Guglielmoni P, Promsudthi A, Tatakis DN, Trombelli L. Intra- and inter-examiner reproducibility in keratinized tissue width assessment with 3 methods for mucogingival junction determination. J Periodontol 2001;72:134-9.

13. 13 An adequate width of attached gingiva is considered as critical for maintenance of periodontal tissue health by many distinguished researchers. Reference: Friedman and Levine, 1964; Nabers , 1966; Lang and Löe , 1972; Bernimoulin and Mühlemann , 1973; Ochsenbein and Maynard, 1974; Hall, 1981; Matter, 1982 An inadequate zone protect the periodontium from injury occurs due to frictional forces encountered during mastication and dissipate the pull on the gingival margin created by the muscles of the adjacent alveolar mucosa Reference: Friedman, 1999; Ochsenbein , 1960

14. Factors affecting Width of Attached Gingiva 14 Reference: Clinical Periodontology and Implant Dentistry – Jan Lindhe , 5th edition

15. 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 lips or cheek induce movement of free gingival margin. May be due to: 15

16. Objectives to be achieved: 16 Reference: Clinical peridontology 8, 9, 1Oth edition - Carranza F.A., Michael G. Newman.

17. Techniques: 17 Reference: Clinical peridontology 8, 9, 1Oth edition - Carranza F.A., Michael G. Newman.

18. Surgical Techniques for Increasing the Width of Attached Gingiva Vestibular Extension Technique Apically Repositioned Flap Free Autogenous Gingival Grafts Push Back Technique 18 Reference: Gujar and Kathariya , 2014 Reference: Bohannan, 1962 Reference: Freidman and Levine, 1964 Reference: Pennel et al., 1965

19. Vestibular Extension Technique DENUDATION TECHNIQUE Removal of all the soft tissue within an area extending from the gingival margin to a level apical to the mucogingival junction leaving the alveolar bone completely exposed. PERIOSTEAL RETENTION PROCEDURE or SPLIT FLAP PROCEDURE Only the superficial portion of the oral mucosa within the surgical area is removed, leaving the bone covered by periosteum. Crestal bone loss was also observed unless a relatively thick layer of connective tissue was retained on the bone surface. 19 Reference: Ochsenbein 1960; Corn 1962; Wilderman 1964 Reference: Staffileno et al. 1962,1966; Wilderman 1963; Pfeifer 1965 Reference: Costich and Ramjford 1968

20. Conventional Apically Repositioned Flap Involves displacement of soft tissue flaps apically during suturing, leaving 3-5mm of alveolar bone denuded in the coronal part of surgical area. 20 Advantage : Postsurgical Increase in Width of Gingiva Disadvantage : Postsurgical Gingival Recession

21. Modified Apically Repositioned Flap Described by Carnio in 1996 Preserves the Marginal Gingiva 21 Reference: Carnio , J. 1996. The modified technique of apically repositioned flap. Periodonto ., 46:1-6. Advantage : Minimal surgical trauma with no prerequisite of sutures Time requirement is less Reference: Carnio and Miller, 1999.

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24. 24 AIM: A clinical study was carried to compare the CARF with MARF technique in terms of changes in the width of attached gingiva , gingival recession (apparent) , sulcus depth and clinical attachment level MATERIALS AND METHODS: A total no of 14 patients ( 11 males and 3 females ), mean age being 32.14±6.48 (ranges from 23-42 years ) involving 28 sites comprised the study samples. The study was carried out in split mouth design and the sites were designated as Site ‘A’ : treated with conventional apically repositioned flap (CARF) Site ‘B’ : treated with modified apically repositioned flap (MARF) INCLUSION CRITERIA: At least 2 sites with Miller’s Class I recession with sulcus depth of at least 0.5mm Adequate vestibular depth Positive tension test No periapical pathology, dehiscence, trauma from occlusion and within normal arch form Healthy, nonsmoker with no systemic diseases CLINICAL PARAMETERS: Width of attached gingiva Gingival recession (apparent) Sulcus depth Clinical attachment level

25. 25 The clinical parameters were assessed by UNC-15 periodontal probe . The cementoenamel junction (CEJ) was used as a fixed reference point. A stent was fabricated with self cure acrylic resin covering the occlusal/incisal 1/3 rd both buccally and lingually of the teeth to be recorded extending to two adjacent teeth , one on mesial and other on the distal side . Vertical groove corresponding to the midline on the facial aspect of the tooth to be treated was made on the stent to guide the probe during measurements at different time points to make sure that all measurements were made at the same orientation to avoid any discrepancy. The surgical sites were stained with an iodine solution ( Betadine, 0.5% w/v iodine ) to differentiate between alveolar mucosa and keratinized gingiva . This procedure done in each measurement highlighted the MGJ and facilitated the measurement. MEASUREMENTS TAKEN: CEJ to base of sulcus (A) CEJ to gingival margin (B) CEJ to mucogingival junction ( C) PARAMETERS CALCULATED: Width of Attached Gingiva: Distance between base of sulcus to MGJ (C minus A) Apparent Gingival Recession: CEJ to gingival margin(B) Sulcus Depth: Measured from the crest of the gingival margin to the base of sulcus (A minus B) Clinical Attachment Level: Distance from CEJ to base of sulcus (A)

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27. Professional plaque control care was performed weekly during the first 8 weeks . Henceforth, the patients were recalled on days 90 and 150 for evaluation and postoperative measurements. The data were analyzed statistically using paired ‘t’ test and was considered as significant when p value found to be equal or < 0.05 . 27 RESULTS: 1. CHANGES IN WIDTH OF ATTACHED GINGIVA SITE A: the total gain from day 0 to 90 was 1.72mm and from day 0 to 150 was 2.15 mm (significant) SITE B: the total gain from day 0 to 90 was 2.07mm and from day 0 to 150 was 2.25 mm (highly significant) The gain in attached gingiva in Site B was more than that of Site A at different time points 2. CHANGES IN GINGIVAL RECESSION SITE A: the total gain from day 0 to 90 was 0.36mm and from day 0 to 150 was 0.50 mm (highly significant) SITE B: the total gain from day 0 to 90 was 0.43mm and from day 0 to 150 was 0.36 mm (significant) On day 150, the mean difference in the amount of gingival recession in Site B was less than that of Site A , the difference being 0.14 mm.

28. 28 3. CHANGES IN SULCUS DEPTH SITE A: the total gain from day 0 to 90 was 0.43mm and from day 0 to 150 was 0.61 mm (highly significant) SITE B: the total gain from day 0 to 90 was 0.11mm and from day 0 to 150 was 0.21 mm (NOT significant) On day 150, the total increase of sulcus depth in Site A was more than that of Site B ; the mean difference being 0.40 mm. 3. CHANGES IN CLINICAL ATTACHMENT LEVEL SITE A: the total gain from day 0 to 90 was 0.71mm and from day 0 to 150 was 1.04 mm (highly significant) SITE B: the total gain from day 0 to 90 was 0.36mm and from day 0 to 150 was 0.33 mm (NOT significant) On day 150, the mean clinical attachment level in Site A was more than that of Site B ; the difference being 0.71 mm CONCLUSION: MARF technique may be preferred over the former considering the fact that there is no further attachment loss, easy to execute, minimal surgical trauma, less time consuming and, predictable and excellent esthetic results with less/ no resultant gingival recession.

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30. Free Gingival Graft A gold standard for the gingival augmentation procedures 30 Autogenous FGG has been considered the most predictable and popular procedure for increasing the width of keratinized tissue around a tooth with mucogingival defect. Reference: Bjorn H. Free transplantation of gingiva propria. Symposium in Periodontology in MalmöOdontol Revy. 1963; 14:323. Nabers JM. Free gingival grafts. Periodontics. 1966; 4:243–5. Nabers JM. Extension of the vestibular fornix utilizing a gingival graft – Case history. Periodontics. 1966; 4:77–9. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. 1968; 6:121–9. Advantage : High degree of predictability in achieving satisfactory outcome Disadvantage (at Donor Site) : Requires an additional donor surgical site Availability of limited amount of donor tissue Leaves a wound of considerable size in the palatal donor area to heal by secondary intention causing postoperative pain Disadvantage (at Recipient Site) : Esthetic problems due to discrepancies of color and texture between the healed graft and surrounding mucosa A bulky appearance Reference: Haggerty 1966; Nabers 1966; Sullivan & Atkins 1968; Hawley & Staffileno 1970; Edel 1974

31. 31 PREOPERATIVE PHOTOGRAPH POSTOPERATIVE PHOTOGRAPH 15 DAYS 9 MONTHS

32. Acellular Dermal Matrix Allograft Recently introduced in Periodontics as an alternative to FGG in Increasing the width of attached gingival around the teeth Implants In the treatment of gingival recession 32 It is a freeze-dried, cell free, dermal matrix comprised a structurally integrated basement membrane complex and extracellular matrix in which collagen bundles and elastic fibers are the main components Reference: Shulman J. Clinical evaluation of an acellular dermal allograft for increasing the zone of attached gingiva. Pract PeriodonticsAesthet Dent. 1996; 8:201–8. Reference: Callan DP, Silverstein LH. Use of acellular dermal matrix for increasing keratinized tissue around teeth and implants. PractPeriodontics Aesthet Dent.1998; 10:731–4. Reference: Achauer BM, VanderKam VM, Celikoz B, Jacobson DG. Augmentation of facial soft-tissue defects with Alloderm dermalgraft . Ann Plast Surg. 1998; 41:503–7 It is able to act as a bioactive scaffold for migration of fibroblasts, epithelial and endothelial cells and could consistently integrate into the host tissue. Reference: Jhaveri HM, Chavan MS, Tomar GB, Deshmukh VL, Wani MR, Miller PD., Jr Acellular dermal matrix seeded withautologous gingival fibroblasts for the treatment of gingival recession: A proof-of-concept study. J Periodontol . 2010; 81 :616–25

33. 33 PREOPERATIVE PHOTOGRAPH POSTOPERATIVE PHOTOGRAPH 15 DAYS 9 MONTHS

34. 34 AIM: To evaluate and compare the clinical efficacy of free gingival graft (FGG) and acellular dermal matrix (ADM) allograft in the ability to increase the width of attached gingiva. MATERIALS AND METHODS: Fifteen patients ( seven females and eight males ) aged 20–55 years , having two sites with attached gingiva ≤1 mm bilaterally on the facial aspect of the mandibular teeth were selected. INCLUSION CRITERIA: Limited amount of attached gingiva Good oral hygiene Facial probing depths (PSs) ≤2 mm No removable partial denture in the area to be treated Not allergic to any antibiotics or any other drug to be prescribed for the patient No systemic, autoimmune or dermal diseases Nonsmoker CLINICAL PARAMETERS: Plaque index (PI) Gingival index (GI) Probing Depth (PD) Gingival Recession (GR) The width of attached gingiva Were measured at the mid-buccal point of the teeth

35. 35 The junction of the attached and movable tissue was determined by rolling the alveolar mucosa coronally with the side of a probe . During surgery, the extents of the recipient bed and the graft were measured in both the mesio -distal and corono -apical directions . Both pre and postsurgical measurements were made by one examiner (C.A.)only. Measurements were made to the nearest 0.5 mm using a University of North Carolina-15 periodontal probe (Hu- Friedy ) and occlusal stent (with guiding grooves) . For each variable, a patient mean was calculated which was finally subjected for statistical analysis.. POST-SURGICAL CARE: Antibiotics ( amoxicillin, 500 mg, three times a day ( t.i.d ), for 7 days ), analgesics ( ibuprofen, 400 mg, t.i.d for 3 days ) and chlorhexidine ( 0.12% ) mouthwash twice daily for 6 weeks was prescribed to every patient. The patient was advised to refrain from retracting the lips and cheeks and to avoid brushing or flossing in the grafted area for 6 weeks . After 15 days , periodontal dressing and remaining sutures were removed , and the area was thoroughly irrigated with normal saline . The patient was recalled at regular intervals and followed for 12 months postoperatively and at every visit, patient's oral hygiene status was monitored.

36. 36 RESULTS: CLINICAL OBSERVATIONS The wound healing was uneventful without any graft-related adverse effects. The postoperative examination after 12 months revealed increased zone of attached gingiva both in FGG and ADM allograft groups though FGG showed far superior results than the ADM group . On the other, there was an excellent blending of color and texture with the adjacent native tissues at the ADM-treated sites though FGG-treated sites were associated with the slightly different color of the healed tissues with visible borders demarcating the adjacent areas . In ADM allograft group , the epithelization appeared at 4 weeks and keratinization of newly formed attached tissue was not obvious until 6–8 weeks postoperatively . Maturation and stability of the attached gingiva were achieved at 12 weeks and were maintained till 12 months postoperatively. However, the healing period appeared slightly longer for ADM allograft than the FGG . CLINICAL MEASUREMENTS On comparison between baseline and 12 months postoperative evaluation, no statistically significant difference was found for any of the variables. The width of attached gingiva increased significantly following both the treatments. However, the sites treated with ADM allograft demonstrated a comparatively lesser gain in the width of attached gingiva than the FGG-treated sites at 12 months of post-surgery (2.13 mm vs. 4.8 mm, respectively). Comparison of the percentage shrinkage of the grafts between the two groups at baseline and 12 months showed that ADM site had significantly more shrinkage (76.6%) than FGG site (49.7%)

37. 37 CONCLUSION: ADM allograft has resulted in sufficient increase in width of attached gingiva although lesser than FGG. Considering the disadvantages of FGG, it can be concluded that ADM allograft can be used as an alternative to FGG in increasing width of attached gingival in certain clinical situations. The results of the present clinical investigation comparing the effectiveness of FGG and ADM allograft support further studies in this direction to explore the possibility of using ADM allograft as a substitute to FGG in augmenting the areas deficient in keratinized gingiva.

38. REFERENCES Clinical Periodontology and Implant Dentistry – Jan Lindhe , 5th edition Clinical peridontology 8, 9, 1Oth edition - Carranza F.A., Michael G. Newman Nabers JM. Free gingival grafts. Periodontics. 1966; 4:243–5. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. 1968; 6:121–9. Bjorn H. Free transplantation of gingiva propria. Symposium in Periodontology in MalmöOdontol Revy. 1963; 14:323. Achauer BM, VanderKam VM, Celikoz B, Jacobson DG. Augmentation of facial soft-tissue defects with Alloderm dermalgraft . Ann Plast Surg. 1998; 41:503–7 Haggerty 1966; Nabers 1966; Sullivan & Atkins 1968; Hawley & Staffileno 1970; Edel 1974

39. The way to get started is to quit talking and begin doing. Walt Disney 39