Periodontal plastic and esthetic surgery

This presentation includes all types of plastic periodontal and esthetic surgeries.

1. Periodontal Plastic and Esthetic Surgery Dr. Diana Mostafa Abo El Ola

2. Periodontal plastic surgery Is the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa.

3. Includes 1- Periodontal-prosthetic correction 2- Crown lengthening 3- Ridge augmentation 4- Esthetic surgical correction 5-Coverage of denuded root surface 6-Reconstruction of papillae 7- Esthetic surgical correction around implant 8- Surgical exposure of unerupted teeth for orthodontics Crown lengthening by flap Crown lengthening by gingivectomy (gummy smile treatment ) Coverage of denuded root Surgical exposure for canine

4. Objectives of plastic surgery 1-Treat problems associated with mucogingival conditions. 2-Improve esthetics by esthetic surgery. 3-Tissue engineering (GTR , ADM . etc ). Shallow vestibule Attached gingiva Aberrant frenum Narrow zone of attached gingiva Shallow vestibule Aberrant frenum

5. Techniques for increasing the attached gingiva

6. Objectives: Enhances plaque removal Improves esthetics Reduces inflammation around restored teeth Allows gingival margin to bind better around teeth and implants with attached gingiva. Before & after

7. Techniques to Increase Attached Gingiva 1- Free gingival autograft 2- Free connective tissue autograft 3- Apically positioned flap Gingival augmentation apical to the area of recession Gingival augmentation coronal to the recession Graft is placed on recipient bed apical to recessed GM (No coverage of root surface) Graft placed to cover the denuded root surface . (root coverage) 1- FGG & Free CT autograft 2- Pedicle autografts Laterally positioned pedicle F. Coronally positioned flap include Semilunar pedicle 3-Subepithelial connective tissue graft 4-GTR 5-Pouch and tunnel technique , Vista, pinhole technique.

8. Gingival augmentation apical to recession 1- Free gingival autograft 2- Free connective tissue autograft 3- Apically positioned flap

9. Step 1: Prepare the recipient site Prepare a firm connective tissue bed to receive the graft. The recipient site can be prepared by incising at the existing mucogingival junction with a ≠15 blade to the desired depth.  Step 2: Obtaining graft from the donor site : transferring a piece of keratinized gingiva approximately the size of the recipient site Palate is (a partial thickness graft usual site from which donor tissue is removed the is used). The ideal thickness is 1 -1.5mm. Step 3: Transfer and immobilize the graft : position the graft and adapt it firmly to the recipient site.   Step4: Protect the donor site: with a periodontal pack for a week  Free Gingival Autografts

10. Incision is done by # 15 blade at MGJ Blending incision on both sides( intacted periosteum) Donor site: palatal strip(no suture) K.epitheluim+thin layer of underlying CT(1-1.5mm) Placement of free gingival autograft

11. Use of free gingival graft from the palate to increase the attached gingiva.

12. Healing of the autograft Success of graft depends on survival of the CT . The 1 st day graft becomes edematous & undergo degeneration & necrosis in some areas. Revascularization of the graft starts after 2-3 days. Recipient bed Capillaries proliferate to graft and form new capillaries Thin epithelial layer formed on 4th day What if the graft is too thin ? Too thick ? If too thin…………necrosis of graft & exposure of recipient site. If too thick…………deeper wound in palate that may injury major palatal arteries.

13. 2-Free Connective tissue autograft Divergent vertical incision, Split flap Transfer graft to recipient site +suturing Obtain CT graft from palate then suturing preoperative postoperative CT autograft

14. Advantages 1- Very predictable . 2- Smaller donor site (than FGG). 3- CT will carry the genetic message for overlaying epithelium to become keratinized. 4- Donor site will heal by 1 st intension. 5-Better esthetics and color (than FGG). Disadvantages 1- Need 2 surgical sites. 2- Technique sensitivity. Contraindications 1- All exposed dentin (no cementum). 2- Abfraction . 3- Tissue at or near CEJ. 4- Gingival hyperplasia.

15. 3-Apically positioned flap Adequate vestibule must be present to allow apical displacement of the flap. It Increases width of Keratinized gingiva but not increasing vestibule depth.

16. An internal bevel incision is done< 1mm from crest of gingiva & directed to crest of bone. Crevicular incisions and elevation of flap are done. Vertical incision is done extending beyond the mucogingival junction. Full thickness flap is elevated by elevator. Split thickness flap is elevated using sharp dissection with blade. SRP and debridement if required. Place the flap apically and sling suture is done in case of full thickness while direct loops is done in the partial thickness flap. A dry foil is placed over the flap before covering it with pack

17. The edge of the flap may be located in 3 positions in relation to the bone Slightly coronal to the crest of the bone Preserve the attachment of supracrestal fibers. Give thick gingival margins. At the level of the crest Satisfactory gingival contour . 2mm short of the crest Produce most desirable , firm tapered gingival margin.

18. Internal bevel incision Horizontal incision Sutured apically postoperative A horizontal beveled incision is done by blade 0.5mm coronal to MGJ into attached gingiva. Modified apically repositioned flap

19. Gingival Augmentation Coronal to Recession (Root Coverage) 1- FGG & Free CT autograft 2- Pedicle autografts Laterally positioned flap- Double positioned flap Coronally positioned flap includes Semilunar pedicle 3-Subepithelial connective tissue graft 4-GTR 5-Pouch and tunnel technique 6- Vista technique 7- Pin hole technique 8-Coronally positioned Flap

20. Marginal Tissue Recession Etiology Tooth brushing trauma. Periodontal diseases Tooth malposition. Bone dehiscence. High muscle attachment and frenal pull. Orthodontic tooth movement through a thin buccal osseous plate.

21. Diagnosis & prognosis Class I & II : good-excellent Class III : Partial coverage Class V : Poor prognosis

22. Which 1 is more esthetic?? 1- FGG & 2- CTG FGG(more whitish in color) CT autograft More esthetic

23. 2- Pedicle autografts It is a soft tissue graft that is not completely detached from one site and transferred to another. According to direction of flap migration  Rotational flap –Flap rotated or displaced laterally  Laterally positioned flap  Double papillae flap  Trans positional flap   Advanced flap - Flap placed with out rotation or lateral migration  Coronally positioned flap  Semilunar flap 

24. Lateral (horizontal )positioned flap Donor site: adequate vestibule & AG Slide flap laterally to adj. tooth without any tension postoperative Advantages  One surgical site (no donor tissue) . It offers the best blood supply to the donor tissue because it maintains a connection between the donor tissue and the origin of the graft . Postoperative color is in harmony with surrounding tissue .

25. Remember The periodontium of the donor site should have satisfactory width of attached gingiva & minimal loss of bone without dehiscence or fenestration.  A partial thickness flap is preferable because it offers the advantage of rapid healing at the donor site and reduces risk of loss of facial bone height. 

26. Coronally positioned flap Preoperative Split thickness flap 2 diverging vertical incisions beyond MGJ Coronallly sutured Split technique 2 diverging vertical incisions beyond MGJ Return flap coronal to the postion The purpose →is to create a split thickness flap in the area apical to the denuded root and position it coronally to cover the root.  Results are unfavorable because of insufficient keratinized gingiva apical the recession. It needs keratinized gingiva ≥ 3mm. 

27. Semilunar pedicle Semilunar incision following the curvature of receded gingival margin It may need to reach alveolar mucosa if attached gingiva is narrow. Split thickness dissection coronally from incision+ connect it to an intrasulsular incision. Flaps collapse covering recession SRP should be done

28. Apical semilunar incision Intrasulular incision Coronally advanced flap Adv. Of coronally advanced flap: Simple and can be done for more than one tooth. One surgical site. Indications: 2-3 mm recession. Thick gingival biotype. Maxillary teeth, y???because of the gravity direction. Pre-operative Post-operative

29. Indicated for larger & multiple defects. Take a CT from palate flap (donor site). Donor site heals with 1ry intention + more esthetic results. The graft is sandwiched between the split flap. 3- Subepithelial connective tissue graft

30. Vertical incisions extend beyond MGJ(split thickness) CT graft cover denuded root SRP & Root conditioning should be done Flap sutured over the graft Postoperative

31. Alternative donor site Because Use of palate as a donor site make patients afraid And working in 2 surgical sites Acellular dermal matrix(ADM)“ALLODERM” From human skin

32. Acellular dermal matrix is a prepared biocompatible graft that acts as a biologic regenerative matrix or scaffold for the ingrowth of undifferentiated mesenchymal and endothelial cells.  Studies reported that → it is clinically effective and highly predictable and compares favorably with subepithelial connective tissue graft.  Ability to cover an unlimited number of sites without the need for a second surgical site → significant advantage. 

33. 4-Guided tissue regeneration(GTR) Using resorbable membrane - GTR is used to reconstruction of periodontium apparatus along with coverage of denuded root. -FGG & Subepithelial CT graft are much better.

34. 5-Pouch & tunnel technique (coronally advanced tunnel tech) Advantages To decrease incisions & reflection. To provide good blood supply. Allow intimate contact of donor tissue to the recipient site (stability). Excellent esthetics. Thickening of gingiva. Disadvantage Requires 2 surgical sites (if using autograft). Technique sensitive.

35. Steps Vertical and Intrasulcular incision. Dissect the connective tissues beyond MGJ & papilla are kept intact. Mattress suture placed at end of graft to guide graft through sulcus. No dressing , only daily CHX+ antibiotics. Intact papillae

36. 6-Vista technique (Vestibular Incision Subperiosteal Tunnel Access)

37. 7- Pin hole technique

38. Factors that affect Plastic surgery outcome 1- Irregularities of teeth -It affects location of gingival margin, width & alveolar bone height and thickness. - Malposed tooth with thin plate of bone→ results root exposure. 2- MGJ Anterior……3mm apical to radicular bone 5mm interdentally In periodontal disease, bone margin may locate at or beyond the MGJ.

39. Treatment of the shallow vestibule

40. Problems Associated with Shallow Vestibule: Gingival Recession reduces the vestibular depth. Adequate vestibular depth is necessary for proper brushing (OH) & retention of prostheses. It can be done by free autogenous autograft tech. Vestibule deepening surgery Using autograft to increase depth of vestibule Inadequate vestibule

41. Ventriculoplasty techniques 1-Mucosal advancement vestibuloplasty a)Closed submucosal vestibuloplasty b)Open submucosal vestibuloplasty 2-Secondary epithelization (re-epithelialization vestibuloplasty ) a)Kazanjian’s technique b)Clark’s technique 3-Grafting vestibuloplasty

42. Closed submucosal vestibuloplasty Vertical incision extends from MGJ to labial mucosa, then deepened to reach periosteum. Blunt dissection and tunnels are done. A wedge shape strip of connective tissue remains between submucosal tunnel and subperiosteal tunnel. Then, this wedged shaped tissue is excised. Stent is placed to retain the mucosa in the position. Then, removed after 1 week. Open Submucosal Vestibuloplasty A horizontal incision through mucosa at the MGJ is done. Mucosa is dissected from submucosa towards the lip. Sutures are placed to fix the periosteum deep in the vestibule. The free margins of the flap are returned to their original position and sutured. 1-Mucosal advancement vestibuloplasty

43. Kazanjian’s Technique Incision is made in labial mucosa. The labial and vestibular mucosa is reflected . Vestibule is deepened to the desired depth by supraperiosteal stripping. Mucosal flap is turned down from its attachment on alveolar ridge and placed against periosteum. Then, sutured. The labial tissues is healed by secondary epithelization. A stent is placed for 1 week to maintain depth of the vestibule. Labial incision is made and mucosal flap is raised from labial surface. Supraperiosteal dissection is done,Periosteum is incised on the crest of alveolar ridge and sutured to the denuded labial submucosal surface. Mucosal flap is sutured over the denuded bone to inferior attachment of periosteum. This is called transpositional flap because labial & periosteal flaps are interchanged to line the opposing surface. Lipswithch vestibuloplasty 2- re-epithelialization vestibuloplasty

44. Clark’s technique Horizontal incision is done on alveolar ridge just buccal to crest of the ridge . A supraperiosteal dissection is done, the lip mucosa is undermined until the vermillion border. The free margin of the mucosal flap is sutured to depth of newly created vestibule. The osseous side left with raw periosteal surface to granulate and epithelialize secondarily. This technique has high liability of relapse as the lip musculature tot alveolar bone shift towards the alveolar crest, obliterating the sulcus.

45. 3- Grafting vestibuloplasty Clarks vestioplasty can be done followed by covering the raw periosteal surface by soft tissue graft .

46. Techniques for removal of frenum

47. High frenum attachments

48. Problems Associated with Aberrant Frenum: When the frenum invades on the GM 1-Interferes with plaque removal. 2-Its tension → open the gingival sulcus & pull GM away from tooth → Cause esthetic problem Rx : Surgical removal of the frenum(frenectomy/frenotomy).

49. Frenectomy → is the complete removal of the frenum, including its attachment to the underlying bone (required in the correction of abnormal diastema between the maxillary central incisors).   Frenotomy → is the relocation of frenum, usually in a more apical position. 

50. Superior & inferior margins are grasped by curved mosquito hemostats Excision of frenum from posterior surface of L. hemostat until U. hemostat Remove the hyperplastic tissues Undermining the mucosa from underlying tissues Suturing in the middle of wound to facilitate subsequent suturing

51. Techniques to improve esthetics

52. Esthetic Surgical Therapy -Root coverage -Regeneration of lost or reduced papillae ,Black triangle (black hole) -Gummy smile (excessive gingival display) Rx: Not predictable

53. 1- Root coverage surgery 1- FGG & Free CT autograft 2- Pedicle autografts Laterally positioned and double positioned flap Coronally positioned and Semilunar pedicle 3-Subepithelial connective tissue graft 4-GTR 5-Pouch and tunnel technique 6-Coronally positioned Flap

54. 2-Reconstruction of papilla preoperative: loss of ID papillae + class IV CT graft +bone from tuberosity Coronally positioned flap

55. 3-Correction of gummy smile Causes of gummy smile - Vertical maxillary excess…( orthognathic treatment) - Dentoalveolar extrusion…( ortho. Rx) - Incomplete exposure of the anatomic crown “altered passive eruption”…..(crown lengthening surgery) - Short upper lip or excessive lip translation ….(Botox or filler )

56. C rown Lengthening Rx: Gingivectomy Or Osseous surgery

57. Crown lengthening with osseous reduction

58. Tissue engineering

59. The future of periodontal plastic surgery will encompass the use of tissue-engineered products at the recipient site to reduce donor site morbidity. Results of numerous experimental and clinical studies support the clinician's use of a minimally invasive approach to periodontal plastic surgery. Ex.Alloderm , biological mediators.

60. Alloderm is sutured in a pouch with coronally displaced flap

61. Use of enamel matrix derivates with coronally displaced flap to treat recession

62. 3 mm recession was treated by human platelet derived growth factor +beta tricalcium phosphate + collagen wound dressing with coronally displaced flap (GTR).

63. Criteria for selection of technique 1- Surgical site : free from plaque/calculus & no inflammation(should be firm). 2-Adequate blood supply Apical Gingival augmentation > coronal Gingival augmentation Pedicle graft(the best) >free autograft. 3- Anatomy of recipitent and donor site FGG & CTG →create vestibular depth +widening AG (Other techniques need adequate vestibule). Donor site should be thick gingival biotype. 4- Stability of graft 5- Minimal trauma Poor incision, perforation, tearing or excessive suture→→cause tissue necrosis. Proper instruments selection+ Sharp blades+ smaller diameter needles+ resorbable monofilament sutures are needed.

64. This the meaning of Plastic Surgery