NSPT and Periodontal Surgery

1.) All of the following are contraindications or reasons for a delay in periodontal surgery except one. Which one is the exception?

a) Poor oral hygiene

b) Periodontal abscesses

c) Unstable hypertension

d) Intravenous bisphosphonates

e) Uncontrolled diabetes mellitus

a) Poor oral hygiene

b) Periodontal abscesses

c) Unstable hypertension

d) Intravenous bisphosphonates

e) Uncontrolled diabetes mellitus

2.) Which of the following types of surgery is best to treat a periodontal bony lesion with deep pockets and vertical bone loss (three-wall defect)?

a) Connective tissue graft

b) Free gingival graft

c) Modified Widman flap

d) Regenerative bone graft

a) Connective tissue graft

b) Free gingival graft

c) Modified Widman flap

d) Regenerative bone graft

3.) Which of the following periodontal conditions is best treated with a subepithelial connective tissue graft?

a) Three wall bony defect

b) Soft tissue recession with root exposure

c) One wall bony defect

d) Class III furcation defect

a) Three wall bony defect

b) Soft tissue recession with root exposure

c) One wall bony defect

d) Class III furcation defect

4.) Which of the following healing responses of periodontal tissues after surgery describes the reformation of tissues that were destroyed due to periodontal disease?

a) New attachment

b) Repair

c) Regeneration

d) Reattachment

a) New attachment

b) Repair

c) Regeneration

d) Reattachment

5.) Which one of the following should be used by a patient to help reduce inflammation and swelling immediately after periodontal surgery?

a) Ice packs

b) Salt water rinsing

c) Aspirin

d) Heat packs

a) Ice packs

b) Salt water rinsing

c) Aspirin

d) Heat packs

6.) Which of the following surgical techniques is indicated for a patient who has gingival enlargement due to nifedipine but no bone loss?

a) Free gingival graft

b) Gingivectomy

c) Connective tissue graft

d) Osseous surgery

a) Free gingival graft

b) Gingivectomy

c) Connective tissue graft

d) Osseous surgery

7.) Which of the following defects heals best with periodontal surgical regeneration?

a) Grade III maxillary molar furcation

b) Horizontal bone loss

c) Three wall bony defect

d) One wall bony defect

a) Grade III maxillary molar furcation

b) Horizontal bone loss

c) Three wall bony defect

d) One wall bony defect

8.) Which of the following bone grafts is taken from an existing mandibular tori in the patient's mouth?

a) Autograft

b) Allograft

c) Xenograft

d) Alloplast

a) Autograft

b) Allograft

c) Xenograft

d) Alloplast

9.) Which of the following bone grafts is taken from human cadavers?

a) Xenograft

b) Alloplast

c) Autograft

d) Allograft

a) Xenograft

b) Alloplast

c) Autograft

d) Allograft

10.) Which of the following materials is used to inhibit epithelial migration into the surgical site?

a) Bone grafts

b) Barrier membranes

c) Sutures

d) Connective tissue

a) Bone grafts

b) Barrier membranes

c) Sutures

d) Connective tissue

11.) Which of the following terms is used for a surgical procedure that will impede the epithelial migration during healing of the periodontal wound?

a) Guided tissue regeneration

b) Incision and drainage

c) Gingival curettage

d) Connective tissue graft

a) Guided tissue regeneration

b) Incision and drainage

c) Gingival curettage

d) Connective tissue graft

Name four Phase I Goals of Treatment:
a.

b.

c.

d.

Name four Phase I Goals of Treatment:
a. complete removal of calculus

b. correction/replacement of poorly-fitting restorations and prosthetics

c. restoration of caries

d. extraction of hopeless teeth

Re-evaluation of tissue response should occur _____ to _____ weeks after periodontal debridement (non-surgical).

Re-evaluation of tissue response should occur 4 to 8 weeks after periodontal debridement (non-surgical).

Non-surgical debridement becomes less effective when probing depths are above _____ mm.

Non-surgical debridement becomes less effective when probing depths are above 4 mm.

TRUE or FALSE: A gain in clinical attachment is possible with non-surgical therapy.

FALSE

The rate of subgingival biofilm recolonization is dependent upon ____________________________.

The rate of subgingival biofilm recolonization is dependent upon supragingival biofilm accumulation (oral hygiene self-care).

TRUE or FALSE: NSPT is used to regenerate tissues.

FALSE

Following NSPT, the epithelium forms a ________ ___________ ____________.

Following NSPT, the epithelium forms a long junctional epithelium.

In the lamina propria, the inflammatory infiltrate will be replaced by collagen but the JE does not allow a new CT attachment to form. Why?

NSPT allows for the repair, not the regeneration, of tissues. The healed tissue is a scar, and the destroyed CT attachment is replaced with a long JE. The destruction/damage done to the CT attachment and root surface CANNOT return to a state of pristine health, nor can it be regenerated via NSPT.

Repair and healing can be altered and/or delayed in patients who are:

a.

b.

c.

Repair and healing can be altered and/or delayed in patients who are:

a. diabetic

b. immunocompromised

c. smokers

Reduction in probing depths after NSPT is due to what?

A combination of gingival recession (shrinkage) and an increase (NOT regeneration!) of the clinical attachment (top of the long JE).

Periodontal debridement becomes less effective in pockets that are _____________.

Periodontal debridement becomes less effective in pockets that are >4mm.

Re-evaluation of initial therapy includes:

a.

b.

c.

d.

Re-evaluation of initial therapy includes:

a. Tissue response and condition (color, contour, texture, consistency)

b. Probing depths, BOP, CAL

c. Mobility and furcation involvement

d. Evidence of inflammation

Name five objectives of periodontal therapy:

a.

b.

c.

d.

e.

Name five objectives of periodontal therapy:

a. Reduction in pocket depth to allow for better access for plaque control; to create an oral environment that is maintainable by the pt and DH

b. Gain access to the root and underlying bone, removing remaining calculus, smoothing out gouges and Sharpey’s fibers pits

c. Regenerate periodontal tissues destroyed due to disease

d. Arrest disease progression

e. Improvement of the prognosis of teeth and their replacements, including esthetics

Name five contraindications or precautions for periodontal surgery:

a.

b.

c.

d.

e.

Name five contraindications or precautions for periodontal surgery:

a. uncontrolled DM

b. HIV

c. smokers

d. CV conditions

e. pts who are noncompliant with plaque control or perio maintenance appts

DEFINE:
a. reattachment

b. regeneration

DEFINE:
a. reattachment: reunion of epithelial or connective tissue to a root surface that was not damaged or destroyed by periodontal disease

b. regeneration: attachment apparatus (bone, cementum, PDL) is reformed on a root surface that was previously pathologically exposed

Epithelial tissues are fast-growing and can migrate up to ______ mm/day.

Epithelial tissues are fast-growing and can migrate up to 0.5 mm/day.

How does the fast-growing epithelial tissue interfere with healing and regeneration?

Epithelial growth occurs faster than bone and CT, allowing it to displace bone and tissue grafts and to prevent angiogenesis.

DEFINE:

a. full- (mucoperiosteal) thickness flap

b. partial- (split) thickness flap

DEFINE:

a. full- (mucoperiosteal) thickness flap: gingiva, alveolar mucosa, and periosteum are reflected from the root and underlying bone surface

b. partial- (split) thickness flap: periosteum and some gingival connective tissues are left attached to the bone and are not included in the reflected flap

Why is a crown lengthening procedure done?

A crown lengthening procedure exposes more tooth structure (creates an area for supracrestal tissue attachment) for the purpose of properly restoring a tooth, especially one that is fractured or decayed close to/at/apical to the AC.

DEFINE:
a. ostectomy

b. osteoplasty

DEFINE:
a. ostectomy: removal of tooth-supporting bone

b. osteoplasty: reshaping

A ____ -wall bony defect responds best to regeneration.

A 3-wall bony defect responds best to regeneration.

DEFINE:

a. autogenous

b. allograft

c. xenograft

d. DFDBA

e. osteogenic

f. osteoinductive

g. osteoconductive

DEFINE:

a. autogenous: material harvested from one part of the body and grafted to another part of the pt’s body; the gold-standard grafting material; osteogenic

b. allograft: material obtained from other individuals of the same species but that are genetically different; osteoinductive

c. xenograft: type of natural bone substitute obtained from a genetically-different species; osteoinductive when used with allografts or osteoconductive when used alone

d. DFDBA: demineralized freeze-dried bone allograft; one of the main forms of bone allografts; osteoinductive

e. osteogenic: process of new bone formation by bone cells from the host or the graft; ex: autogenous bone (autograft)

f. osteoinductive: mesenchymal stem cells from the graft are induced to differentiate into osteoblasts which produce new bone; ex: allografts like DFDBA, BMP-2, and growth factors like PDGF

g. osteoconductive: bone material serves as a scaffold or filler that allows bone from the surrounding area to grow over and into them; does NOT produce new bone and requires the presence of existing bone; ex: alloplasts, xenografts when used alone

Name four adverse effects of periodontal surgical procedures:

a.

b.

c.

d.

Name four adverse effects of periodontal surgical procedures:

a. cellulitis/infection

b. tooth mobility

c. gingival recession

d. loss of sensation

Name the three types of soft tissue grafts:
a.

b.

c.

Name the three types of soft tissue grafts:
a. pedicle graft

b. free gingival graft (FGG)

c. connective tissue graft (CTG)

Which type of soft tissue graft is better for augmentation of attached gingiva than for esthetic results?

free gingival graft (FGG)

Which type of soft tissue graft is better for esthetics and root coverage?

subepithelial connective tissue graft (CTG)

Name two sources of tissue for soft tissue grafts:
a.

b.

Name two sources of tissue for soft tissue grafts:
a. surface of palate

b. underneath surface of palate

Debridement

The rate of subgingival biofilm recolonization is dependent upon supragingival biofilm accumulation, making OH self-care and professional periodontal debridement essential!

• Oral prophylaxis: removal of biofilm, calculus, and stains from the exposed and unexposed surfaces of the teeth by scaling and polishing as a preventive measure for the control of local irritants

• Periodontal debridement: removal of calculus, debris, and dental biofilms and their byproducts from the tooth surface and gingival crevice to treat gingival and periodontal inflammation

• NSPT (initial phase/Phase I): thorough debridement in conjunction with a high degree of oral hygiene with the goal of returning the tissue to a state of “maintainable health” and a reduction of inflammation

  • SRP = scaling and root planing

    • scaling: removal of dental biofilm, calculus, and stains from tooth surface

    • root planing: removes necrotic cementum and surface dentin that is rough, impregnated with calculus, or contaminated with toxins (LOS) or microorganisms

    • the removal of subgingival microbial flora results in a delay in repopulation of pathogenic microbes

• Surgical Intervention (Phase II):

  • gain access to the root and underlying bone to remove any remaining calculus, smooth out existing gouges and Sharpey’s fiber pits

  • regenerate periodontal tissues destroyed due to disease

  • arrest disease progression

  • reduce pocket depth to allow for better access for plaque control, improve the prognosis of teeth and their replacements

  • esthetic improvement

  • to create an oral environment that is maintainable by the pt and DH

NSPT (Non-surgical Periodontal Treatment)

Goals of NSPT:

Immediate goal: to prevent, arrest, control, or eliminate periodontal diseases

Ideal goal: promote healing through regeneration of lost form, function, esthetics, and comfort

Accepted goal: to repair damaged tissue

Ultimate goal: to sustain masticatory system in a state of health

.
Determinants of Success:

• use of appropriate equipment, professional knowledge, skill, experience, knowing your capabilities

• pt compliance

• severity of disease

• host immune response

.

Limitations of Periodontal Debridement:

• becomes less effective when PD >4mm

• increased PD → greater % of tooth surfaces exhibit residual calculus

  • NSPT: 17-69% residual

  • surgical access: 14-24% residual

• concavities

• furcations

.

Outcomes of Periodontal Debridement

Measurable endpoints: CAL, PDs, visual signs of inflammation, reduction in BOP % score, reduction in PI score, alterations and reductions in subgingival biofilms

Phase I

Goals:

• complete removal of calculus

• correction or replacement of poorly fitting restorations and prosthetics

• restoration of caries

• orthodontics

• elimination of food impaction areas

• management of occlusal trauma

• extraction of hopeless teeth

• antimicrobials and host modulators

.

Sequence:

1. OHI (plaque control instruction)

2. Scaling (removal of sub and supragingival deposits)

3. Recontouring defective restorations and crowns

4. Caries control

5. Tissue reevaluation

Tissue Changes After Periodontal Debridement: Gingivitis

Once biofilm and calculus are removed, healing occurs…

• pocket epithelium → JE → forms an attachment to adjacent tooth surface via hemidesmosomes

• inflammatory infiltrate → gradually replaced by maturing collagen fibers → organize into functionally orientated bundles

• final healing = long junctional epithelium

• color changes: red → uniform pink

• PD changes → formation of a physiological gingival sulcus with a goal of a “normal” PD of 1-3mm

Since there was NO loss of attachment and the root surface was not damaged, gingivitis is considered REVERSIBLE. Healing results in tissues that are restored to CLINICAL GINGIVAL HEALTH (but NOT PRISTINE).

Tissue Changes After Debridement (NSPT/SRP): Periodontitis

Once biofilm and calculus are removed, healing should occur…

• pocket epithelium → JE → covers the root surface down to the base of the original pocket (long epithelial attachment)

• epithelial cells move very quickly to repopulate the root surface

• inflammatory infiltrate of lamina propria → replaced by collagen, but the fast reproduction of the JE does NOT allow a new CT attachment to form

.

Complete healing in 1-2 weeks depends on:

• severity of inflammation

• PD

• effectiveness of debridement

• resolution of inflammation

.

Host repair and healing capacity are altered with:

• diabetes

• immunocompromised host

• smoking status

Gain in Clinical Attachment

REPAIR ≠ REGENERATION

Non-surgical (Periodontal Debridement/NSPT): removal of plaque biofilms, calculus, and contaminated cementum → eliminates inflammation and allows tissues to REPAIR

Surgery: attempts are made for REGENERATION

---

Connective Tissue Attachment Level: the level on the root at which the most coronal fibers are attached (histologically); corresponds roughly to the base of the pocket as identified by probing in periodontitis

• a “gain” in clinical attachment refers to a DECREASED PENETRATION OF THE PROBE at the base of the pocket after tx, NOT new connective tissue attachment

• reduction of pocket depths = long epithelial attachment (NO real CT attachment is reformed — the JE is a weak attachment and can easily let go, contributing to the pt’s high susceptibility for recurrence of periodontitis)

Factors Affecting CAL Measurement:

• pseudopocket (gingival inflammation = coronal migration of FGM)

• probing technique (overangulation, pressure and integrity of JE)

• tooth anatomy

• presence of calculus (probe hits calc and not the pocket base)

• reduction in PD due to recession and/or an increase in clinical attachment via the top of a long JE

Cementum and NSPT

When exposed in a periodontal pocket, cementum…

• becomes contaminated

• endotoxin (LOS) is loosely and superficially attached to the root surface (no need for extensive root planing)

• calculus forms in Sharpey’s fibers pits

Note: It is NOT always easy to determine the end point for debridement!

Reevaluation of Initial Therapy

Purpose: Determine the need for Phase II (Surgical Intervention)

• tissue response (evaluated after 4-8 wks)

  • color, contour, texture, consistency

  • BOP / Evidence of Inflammation

  • PD

• OIC

• Mobility

• Furcations

• CAL

Phase II (Surgical Intervention)

Types of Periodontal Surgery:

• Gingivectomy

• Gingivoplasty

• Periodontal Flap Surgery

• Flap Surgery with Osseous Recontouring

• Periodontal Plastic Surgery

• Periodontal Regeneration

---

Indications:

• Pocket elimination/reduction

• Correction of mucogingival defects

  • root coverage

  • increase in keratinized/attached gingiva

• Create a favorable restorative environment

  • crown lengthening (restoring supracrestal attachment)

• Esthetics

.

Contraindications: Systemic diseases that CANNOT BE CONTROLLED by medications or otherwise

• uncontrolled DM

• CV conditions

• HIV

• smokers

• bleeding disorders (hemophilia, blood thinners)

• IV bisphosphonates

• noncompliance with plaque control or perio maintenance appts

• concern for cosmetic outcome

• hopeless teeth

---

Preoperative Preparation:

• successful completion of Phase I (increases manageability of tissues during surgery and better healing)

• addressed uncontrolled/poorly controlled systemic diseases

• elimination of plaque-retentive restorations

• endo procedures

• smoking cessation

Postoperative Healing Following Periodontal Surgery

REPAIRATIVE Procedures (not regenerative):

• scar formation (healing occurs, but scar tissue is different from original tissue)

• destruction of CT attachment is healed with a long JE

Reattachment: reunion of epithelium or CT to a root surface that was not damaged or destroyed by periodontal disease

Regeneration: attachment apparatus (bone, cementum, & PDL) is reformed on a root surface that was previously pathologically exposed

• regeneration is the IDEAL healing response but is NOT ALWAYS ATTAINABLE (usually a PARTIAL regeneration is obtained)

• epithelial cells migrate (0.5mm/day) MUCH FASTER than bone or CT which interferes with total regeneration

• epithelial growth can displace bone/tissue grafts and can prevent angiogenesis

Periodontal Surgery: Gingivectomy/Gingivoplasty

Gingivectomy: excision or removal of gingiva in order to eliminate a pocket

Gingivoplasty: reshaping of gingiva

.

Indications:

• gingival enlargement due to inflammation or medication

• pseudopockets

• suprabony pockets

Contraindications:

• lack of attached gingiva

• infrabony pockets

• limited use

.

Procedure:

• surgical anesthesia

• mark base of pocket

• incision with blade angled 45 degrees to gingiva and apical to the base of the pocket

• a wedge of gingiva is removed (gingivectomy)

• gingivoplasty is performed to reshape gingiva

• complete healing: 4-5 weeks

Periodontal Surgery: Periodontal Flap Surgery

Purpose: to gain access to the root surface and bone

Flap: loosened portion of gingiva and alveolar mucosa that is separated from the underlying structures (except for its base because this is where the flap receives blood supply)

• Full-thickness (mucoperiosteal) Flap: gingiva, alveolar mucosa, and periosteum are reflected from the root and underlying bone surface

• Partial-thickness (split) Flap: periosteum and some gingival connective tissue are left attached to the bone and are not included in the reflected flap

.

Types of Surgical Flap Procedures:

• Pocket Reduction

  • apically-positioned flap

• Bone Graft

  • coronally-positioned flap (attempt to cover surgical site after placement of a bone graft)

• For Improved Periodontal Debridement & Reduction in Inflammation and Pocket Depths

  • Modified Widman Flap (conservative surgical approach with no osseous contouring that better preserves esthetics in mx. ant.)

.

Healing

• tissues look healed within a few weeks

• complete tissue maturation is complete in 1-2 months

Periodontal Surgery: Crown Lengthening

Purpose: expose more tooth structure for the purpose of properly restoring a tooth; creates an area for supracrestal tissue attachment (biologic width)

Indications: teeth that have fracture or decay close to, at, or apical to, the AC of bone

Periodontal Surgery: Treatment of Osseous Defects

• Ostectomy: removal of tooth-supporting bone

• Osteoplasty: reshaping

• Reshaping of Osseous Architecture: both ostectomy and osteoplasty are used to recreate natural contours and relationships; gingiva follows the form of the bone

• Bone Regeneration (Bone Grafts)

Periodontal Surgery: Bone Regeneration (Bone Grafts)

3-Wall Infrabony defects respond BEST with regeneration bone fill because the 3 remaining walls help contain the graft material.

Defects with HBL CANNOT be treated with regenerative surgery because there is no place to put the graft.

.

Types of Bone Regeneration:

• Osteogenic: process of NEW bone formation by BONE CELLS from the host or the graft (e.g. autogenous/autograft)

  • Autogenous bone is considered to be the GOLD STANDARD of grafting materials in terms of stimulating NEW BONE FORMATION

• Osteoinductive: MESENCHYMAL STEM CELLS from the graft are induced to differentiate into osteoblasts which produce new bone (e.g. allografts like DFDBA, BMP-2 / Bone Morphogenic Protein, Growth Factors like PDGF / Platelet Derived Growth Factor, xenografts when used with allografts)

• Osteoconductive: bone material serves as a SCAFFOLD or FILLER that allows bone from the surrounding area to grow over and into them; does NOT PRODUCE NEW BONE; requires the presence of existing bone (more existing bone = greater chance of success); (e.g. alloplasts, xenografts when used alone)

.

Types of Bone Grafts:

• Autografts: bone harvested from one part of the body (mx. tuberosity, edentulous area, chin, extraction socket, mnd. torus, iliac crest) and grafted to another part of the SAME PATIENT’S BODY; osteogenic

• Allografts: bone material obtained from OTHER INDIVIDUALS of the SAME SPECIES but GENETICALLY DIFFERENT (human cadavers); material is sterilized and stored in bone banks, usually in the form of demineralized freeze-dried bone (DFDBA) or freeze-dried bone (FDBA); osteoinductive

• Alloplasts: made of biocompatible, organic, inert materials (synthetic hydroxyapatite, calcium sulfate, bioactive glass, tricalcium phosphate, collagen); osteoconductive

• Xenografts: a type of natural bone substitute derived from a GENETICALLY DIFFERENT species (e.g. bovine); osteoinductive when used with allografts or osteoconductive when used alone

.

Biological Materials: growth factors are only found in LIVING cells (bone, blood platelets, etc.)

• GEM21 (platelet-derived growth factor / PDGF)

• Emdogain (porcine enamel matrix protein derivative, enamel-related proteins from HERS)

• Bone Morphogenic Proteins / BMPs (found in bone and induces new bone formation)

.

Epithelium, Membranes, and Healing

• Membranes are used as barriers to increase the success for bone regeneration.

• Membranes placed over the bony defect with the flap sutured will prevent the epithelium/CT inside the flap from filling in the defect.

• The “space” created between the tooth and the flap by the membrane allows the PDL cells (osteoblasts, fibroblasts, cementoblasts) to migrate from the PDL onto the tooth surface and into the defect.

• Types of Membranes:

  • Nonabsorbable

    • second surgery is needed for removal; first used in clinical periodontics

  • Absorbable

    • preferred membranes because a second surgery is not needed for removal; remain in place for 3-4 weeks

Periodontal Surgery: Root Resection

Root Resection (aka: root amputation, hemisection): removal of a root while leaving the crown on a multirooted tooth

Note: now a rare procedure

Periodontal Surgery: Plastic Surgery

Indications:

• inadequate width and thickness of attached gingiva

• sites that show progressive gingival recession

• sites of inadequate attached gingiva with a subgingival restoration

• sites of inadequate attached gingiva that require orthodontics

• elimination of frenum/muscle pull at or near the GM of a tooth

• base of periodontal pocket extends to, or beyond, the MGJ

Purposes:

• deepen the buccal vestibule for dentures or restorations

• esthetics (cover exposed root surfaces)

• modification (gingival augmentation) of edentulous ridges prior to prosthetic reconstruction

Mucogingival Conditions Around Natural Teeth

Recession: an apical shift of the GM caused by different conditions and pathologies

• associated with clinical attachment loss

• can apply to all surfaces (buccal/lingual/interprox.)

• tendency to increase with age

  • 88% of people aged ≥ 65 years

  • 50% of people aged 18-64

• occurs in populations with both high and low standards of oral hygiene

.

Consequences of Recession/Root Exposure:

• impaired esthetics

• dentinal hypersensitivity

• root caries

• NCCLs (due to abrasion/erosion)

.

Features Used to Describe Mucogingival Conditions Involving Gingival Recession:

• Interdental CAL

• Gingival Phenotype (gingival thickness and KTW)

• Root surface condition (NCCLs, Root Caries)

• Detection of CEJ

• Tooth position

• Aberrant frenum

• Vestibular Depth

• Number of adjacent restorations

NOTE: Mucogingival conditions can be present WITHOUT GINGIVAL RECESSION!

Periodontal Phenotype and Recession

Periodontal Phenotype: determined by the gingival phenotype and bone morphotype; indicates a dimension that may change through time (environmental factors, clinical intervention, etc.) and can be site-specific

• Gingival phenotype: 3D gingival volume considering the thickness of gingival tissue and width of keratinized tissue/KTW)

• Bone morphotype: thickness of buccal bone plate

.

Assessing Periodontal Phenotype:

• KTW = distance from FGM to MGJ

• gingival thickness: observe the probe shining through the gingival tissue after inserting it into the sulcus

  • thin: probe VISIBLE (≤1mm)

  • thick: probe NOT visible (>1mm)

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Notes:

• A THIN phenotype INCREASES the risk for gingival recession and its progression.

• ANY AMOUNT of gingiva is sufficient to maintain periodontal health WHEN optimal OH is attainable (aka an “inadequate” thickness and KTW of gingiva makes optimal OH difficult to achieve)

• there is INCONCLUSIVE DATA that improper toothbrushing influences the development and progression of recession

• there MAY BE AN ASSOCIATION between intrasulcular restorative/prosthetic cervical margin placement and the development of recession particularly in thin phenotypes (gingiva cannot attach to Class V Restorations or NCCLs)

• SEVERAL STUDIES REPORT observation of recession following orthodontic tx (esp. mnd. incisors)

• the development and progression of gingival recession is NOT ASSOCIATED WITH INCREASED TOOTH MORTALITY

• recession is frequently associated with dentin hypersensitivity and carious/NCCLs

• there is NOT ENOUGH EVIDENCE to conclude that surgical root coverage reduces cervical dentin hypersensitivity

• esthetic concerns, dentin hypersensitivity, cervical lesions, thin phenotypes, and mucogingival deformities are best addressed by mucogingival intervention when deemed necessary

Cairo Classification System

• Cairo Classification System: treatment-oriented classification to forecast the potential for root coverage throughout the assessment of interdental CAL

  • RecessionType1 (RT1): recession with NO loss of interprox. attachment

    • CEJ is not clinically detectable at mesial/distal aspects

    • 100% root coverage can be predicted

  • RecessionType2 (RT2): recession WITH loss of interprox. attachment

    • interprox attachment loss is ≤ buccal attachment loss

    • some clinical trials indicate the limit of interdental CAL loss within which 100% root coverage is predictable using root coverage procedures

  • RecessionType3 (RT3): recession WITH loss of interprox. attachment;

    • interprox attachment loss is > buccal attachment loss

    • full root coverage is NOT achievable

Soft Tissue Grafts

Types of Soft Tissue Grafts:

1. Pedicle Graft

   • MOVES (WITHOUT ACTUALLY REMOVING) gingiva from an adjacent tooth/edentulous area with adequate amounts of gingiva (donor site) to an adjacent tooth with inadequate amounts of attached gingiva (recipient site)

   • limited application

2. Free Gingival Graft (FGG)

   • tissue is HARVESTED from the SURFACE OF THE PALATE

   • more predictable for augmentation of attached gingiva than for root coverage

   • not as esthetic as CTG

3. Subepithelial Connective Tissue Graft (CTG)

   • tissue is HARVESTED from UNDERNEATH THE SURFACE OF THE PALATE

   • procedure of choice for root coverage because…

     • less shrinkage of tissue occurs

     • no open wound on palate

     • better blood supply

     • better esthetics (tissue color blend)

   • indicated for single or multiple adjacent teeth with gingival recession and root exposure

4. Allografts (Alloderm)

   • regeneration tissue matrix

   • biomaterial from human tissue with all epidermal and dermal cells removed

   • attempt for root coverage

   • material must be refrigerated and rehydrated

.

Mucosal Release: the mucosa that is flapped back and then stretched over the donor site

.

Periodontal Dressing (Coe-pak)

• some surgeons use a dressing or packing after surgery, but others do not because it creates an anaerobic environment

• a noneugenol, non-irritating/non-burning type is available

• purpose: pt comfort

• stents can be placed over donor sites

.

Surgical Complications

• fear, anxiety, syncope, hypoglycemia, tachycardia from epi (lido 1:50,000), excessive bleeding

• pain (ice pack 15-20 mins on and off to reduce swelling and pain; the more bony involvement and mucosal release, the more pain experienced, use oral analgesics)

.

Postoperative Visit Management

• 7-10 days after surgery for dressing and suture removal, wound cleansing (CHX & H2O2)

• limited OH

.

Adverse Effects

• cellulitis/infection

• brusing

• tooth mobility (should decrease over time/may need occlusal adjustment)

• gingival recession (tissue can rebound, initially scar tissue)

• loss of sensation (scar tissue, paresthesia from swelling/trauma/anesthetic)

• dentinal hypersensitivity

• changes in taste (CHX, dentures)

• open embrasures (may fill in)