Perio 313-Lecture 9

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.