Periodontal Plastic Surgeries Overview

Instructor Information

• Najmeh Ganji, D.M.D, M.S

• Assistant Professor, Department of Periodontology

• Creighton University School of Dentistry

• Board certified in Periodontology and Dental Implant Surgery

Indications for Periodontal Plastic Surgeries

• Before (after) orthodontic treatments

• Patient cannot clean the site

• Esthetics: Enhancing visual outcomes

• Dentinal hypersensitivity: Reducing sensitivity issues

• Before prosthetic treatment

• Evidence of progression: Addressing advancing gum issues

Treatment Planning

Phases of Treatment

1. Disease Control: Managing existing periodontal disease

2. Surgical Phase: Performing the necessary surgical procedures

3. Prosthetic Phase: Involving restorations and other prosthetics

4. Maintenance Phase: Ongoing care and assessment

Patient Evaluation

• Medical and Dental History: Assessing for any contraindications

  • Risk of infection

  • Risk of bleeding

• Personal Habits: Evaluating behaviors like brushing, nail biting, and body piercings that may affect outcomes

• Emphasize the importance of optimal Oral Hygiene (OH) and correcting harmful habits

Candidate Identification for Surgical Procedures

Common Problems Addressed

• Issues related to attached gingiva

• Concerns surrounding a shallow vestibule

• Problems caused by aberrant frenum

• Esthetic crown lengthening: Enhancing tooth appearance

• Papillae reconstruction: Restoring lost tissue between teeth

• Root coverage: Addressing gum recession

Evaluative Considerations

• Can surgery assist in improving oral hygiene?

• Will it help prevent root caries?

• Does it address further recession?

• Assess the patient’s esthetic demands

• Next Steps: Determine the feasibility of suggested treatments

Non-Caries Cervical Lesions (NCCL)

Classifications and Descriptions

• Class A: CEJ visible, without a step

• Class A+: CEJ visible, with a step

• Class B: CEJ not visible, without a step

• Class B+: CEJ not visible, with a step

• Important parameters include:

  • REC: Recession Type

  • Depth: Measurement of gingival recession

  • GT: Gingival Thickness

  • KTW: Keratinized Tissue Width

  • CEJ: Cemento-Enamel Junction

Treatment Approaches for NCCL

• Gingival recession management associated with identifiable lesions

• Utilize Coronally Advanced Flap (CAF) techniques

• Consider connective tissue grafts for better outcomes

Decision Making and Case Selection

Factors to Consider

• Depth of the lesion

• Frenum Attachment: Can affect treatment margin

• Root Prominence: Influences root coverage possibilities

• Presence of NCCL: Awareness of carious involvement

• Phenotype and Thickness: Genotype influences treatment choice

Cairo Classification for Root Coverage

• RT1: Complete root coverage highly possible

• RT2: Complete root coverage possible

• RT3: Complete root coverage unlikely

Additional Considerations

Depth of Defect

• >5mm: Significant depth considerations for treatments

• Associations with frenum attachment, root prominence, and presence of NCCL

Practical Application

• Acknowledge the complexity of clinical decision-making; necessary to consider aesthetic demands and surgical implications.

Surgical Follow-ups

• Pre-operative assessments to post-operative evaluations are critical for long-term success.

• Follow-up imagery and measurements often needed to assess healing and treatment efficacy.

Soft Tissue Substitutes and Grafting

• Common grafting materials include:

  • Acellular Dermal Matrix (ADM)

  • Collagen matrices (synthetic and xenograft)

  • Emdogain: Enamel Matrix Derivatives (EMD)

  • Platelet Rich Fibrin (PRF)

Lingual/Palatal Recession

• Challenges in treating lingual recession include:

  • Lack of evidence, mostly anecdotal reports.

  • Difficulty in access and stabilization of the graft

  • Limited application of the Cairo classification

Patient-Centered Considerations

• Esthetic and Functional Requirements: Assess if the procedures will meet patient expectations without undue morbidity.

• Determine if current conditions indicate a need for intervention.

Final Notes

• Periodontal plastic surgeries demand significant training and knowledge. General dentists should be able to recognize treatment needs and refer appropriately.

• Emphasize ethical responsibility: "Primum non nocere" - First, do no harm - as a guiding principle in treatment planning.