Mucogingival Surgery Perio Plastic Surgery

Question 1

Friedman (Texas Dent J, 1957) described
mucogingival surgery as

Answer 1

plastic surgery
that concerns relations between
mucogingival tissues and attached gingiva,
alveolar mucosa, frenulum, muscle
attachment and vestibule

Question 2

AAP Parameter on Mucogingival Conditions
2000
Definition:
Clinical Features:
Common mucogingival conditions are …. Anatomical variations that may complicate the management of these conditions include …. Variations in — anatomy may be associated with mucogingival con-ditions.

Answer 2

Definition
Mucogingival conditions are deviations from the normal anatomic relationship between the gingival margin and the mucogingival junction (MGJ).

recession, absence or reduction of keratinized tissue, and probing depths extending beyond the MGJ
tooth position, frenulum insertions and vestibular depth
ridge

Question 3

skipped
AAP Classification 1999

Answer 3

AAP Classification 1999
VIII. Developmental or Acquired Deformities and Conditions
A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis
Tooth anatomic factors
Dental restorations/appliances
Root fractures
Cervical root resorption and cemental tears
B. Mucogingival deformities and conditions around teeth
1. Gingival/soft tissue recession
facial or lingual surfaces
interproximal (papillary)
Lack of keratinized gingiva
Decreased vestibular depth
Aberrant frenum/muscle position
Gingival excess
pseudopocket
inconsistent gingival margin
excessive gingival display
gingival enlargement (See LA3. and LB.4.)
6. Abnormal color
C. Mucogingival deformities and conditions on edentulous ridges
Vertical and/or horizontal ridge deficiency
Lack of gingiva/keratinized tissue
Gingival/soft tissue enlargement

Question 4

. Periodontal Biotype/Phenotype
(3)

Answer 4

a. Thin Scalloped
b. Thick Scalloped
c. Thick Flat

Question 5

2. Gingival/Soft Tissue Recession
   (7)

Answer 5

a. Facial or Lingual Surfaces
b. Interproximal (Papillary) Severity of Recession
(Cairo RT 1,2,3)
c. Gingival Thickness
d. Gingival Width
e. Presence of NCCL/Cervical Caries
f. Patient Esthetic Concern (Smile Esthetic Index)
g. Presence of Hypersensitivity

Question 6

6. Gingival Excess
   (4)

Answer 6

a. Pseudo-pocket
b. Inconsistent Gingival Margin
c. Excessive Gingival Display
d. Gingival Enlargement

Question 7

Mucogingival Deformities and Conditions Around Teeth
(7)

Answer 7

1. Periodontal Biotype/Phenotype
2. Gingival/Soft Tissue Recession
3. Lack of Keratinized Gingiva
4. Decreased Vestibular Depth
5. Aberrant Frenum/Muscle Position
6. Gingival Excess
7. Abnormal Color

Question 8

Periodontal Plastic Surgery
* How much is enough?
– Bowers 63: normal varies from — mm
– Lang and Loe 72: need – mm keratinized, – mm
attached
– Maynard and Wilson 79: –mm keratinized needed
for restorative with – mm attached
– Dorfman and Kennedy 80: less than – mm is
adequate if inflammation is controlled
– Freedman et al 99: 18 year study, less than – mm is
adequate if inflammation is controlled

Answer 8

1-9
2, 1
5, 3
1
1

Question 9

Esthetic Enhancement
* Providing a more esthetically
acceptable gingival form and contour
(4)

Answer 9

– Localized gingival recession (today’s topic)
– Localized alveolar ridge deficiency
– Excessive gingival display
– Gingival enlargement or asymmetry

Question 10

Recession definition

Answer 10

• Apical shift of the gingival margin, associated with
  attachment loss
• Etiology-different conditions, pathologies

Question 11

Recession definition
* Apical shift of the gingival margin, associated with
attachment loss
* Etiology-different conditions, pathologies
(4)

Answer 11

– Toothbrush abrasion
– Frenal attachment
– Intrasulcular restorative margin placement*
– Orthodontics-dependent upon direction and bucco- lingual soft
tissue thickness

Question 12

Potential consequences of gingival recession
* Exposed root surface making it potentially more susceptible
to
(4)

Answer 12

– Root caries
– Non-carious cervical lesions (NCCL’s)
– Dentinal sensitivity
– Poor esthetics

Question 13

Localized Gingival Recession
* Etiology-Predisposing factors
(6)

Answer 13

– Inadequate attached gingiva: a dimension not a
measurement (width and thickness)
– Malposed teeth
– TB habit
– Chronic inflammation
– Iatrogenic
– Factitious

Question 14

Localized Gingival Recession
* Etiology-Predisposing Factors
(5)

Answer 14

– Frenulum attachment
– Eruption pattern
– Smokeless tobacco
– Substance abuse (cocaine)
– Orthodontics (?)

Question 15

Localized Gingival Recession
* Treatment Objectives:
(2)

Answer 15

–Root coverage
–Increase the width and thickness of
keratinized tissue

Question 16

Localized Gingival Recession
* Indications:
–Root coverage:
(2)
–Width of keratinized tissue
(2)

Answer 16

• Esthetic concern
• Dentinal sensitivity
• Control of plaque/inflammation
• Prevent further recession

Question 17

Gingival Recession
* Patients over the age of 30 and with
recession :
– 40’s –% have an area of 3 mm of
recession
– 50’s –%
– 60’s –%
– 70’s –%
– 80’s –%

Answer 17

18
30
40
46
60

Question 18

Gingival Recession
* Patients examined and placed in age groups and
followed for progression of recession for 12
years. No comment on oral hygiene level.
* 3 mm of recession sites (2 mm of recession and
one mm of probing depth) had –% of sites
increase in recession.
* 4 mm of recession sites had –% of sites
increase in recession.

Answer 18

67
98

Question 19

Miller’s Classification of Recession
* Class I
(3)

Answer 19

–Marginal recession not extending to
the mucogingival junction
–No loss of interdental bone or soft
tissue
–100% root coverage possible

Question 20

Miller’s Classification of Recession
* Class II
(3)

Answer 20

–Marginal recession extends to or
beyond the mucogingival junction
–No loss of interdental bone or soft
tissue
–100% root coverage possible

Question 21

Miller’s Classification of Recession
* Class III
(3)

Answer 21

– Marginal tissue extends to or beyond the
mucogingival junction
– Loss of interdental bone and/or soft tissue
is apical to the CEJ, but coronal to most
apical extent of recession
– Partial but not total root coverage is
possible (50-70%)

Question 22

Miller’s Classification of Recession
* Class IV
(3)

Answer 22

–Marginal tissue extends to or beyond
the mucogingival junction
–Loss of interdental tissue extends to
the apical extent of recession
–Root coverage cannot be anticipated

Question 23

2017 World Workshop
Change from ‘Biotype’ to ‘Phenotype’
* Biotype:
* Phenotype:

Answer 23

(Genetics) group of organs having same specific
genotype
Appearance of an organ based on multifactorial
combination of genetic traits and environmental factors (its’
expression includes the biotype)

Question 24

• Phenotype may be

Answer 24

modified (environmental factors and
clinical intervention, think soft tissue grafting)

Question 25

Periodontal Phenotype
* Determined by
(4)

Answer 25

– Gingival phenotype (gingival thickness, keratinized tissue width)
– Bone morphotype (thickness of buccal bone plate)
– Thin Phenotype increases risk for gingival recession
– Gingival thickness

Question 26

– Gingival thickness
* <– mm=thin (see probe through tissue)
* >–mm=thick (cannot see probe)
SRM2023

Answer 26

1
1

Question 27

Miller Classification shortfalls
* Clinically may be difficult to identify location of apical
extent of recession as it relates to the mucogingival junction
(MGJ) so hard to determine difference between

Answer 27

Class I
(recession does not extend to MGJ) or Class II (recession
extends to or beyond MGJ)
* Does not identify how much soft or hard tissue loss is
needed to determine if Class III or Class IV

Question 28

Gingival Recession Classification
evaluates attachment loss at

Answer 28

buccal and interproximal sites

Question 29

Recession Type (RT) 1

Answer 29

Recession with no loss of interproximal attachment. Interproximal
CEJ not detectable at both mesial and distal aspects

RT I: Facial or lingual recession with no
interproximal attachment loss

Question 30

Recession Type (RT) 2

Answer 30

Recession associated with loss of interproximal attachment.
However, interproximal attachment loss (measured from
Interproximal CEJ to the depth of the interproximal
sulcus/pocket) is less than or equal to depth of buccal attachment
loss (measured from buccal CEJ to apical extent of buccal
sulcus/pocket)

RT II: Interproximal attachment loss is less
than or equal to the buccal attachment loss
(recession)

Question 31

Recession Type (RT) 3

Answer 31

Recession associated with loss of interproximal attachment.
However, interproximal attachment loss (measured from
Interproximal CEJ to the depth of the interproximal
sulcus/pocket) is higher (greater) than the buccal attachment loss
(measured from buccal CEJ to apical extent of buccal
sulcus/pocket)

RT III: Interproximal attachment loss is
greater than the buccal attachment loss

Question 32

Miller Class I:

Answer 32

Minimal recession, does
not extend to MGJ. No interproximal
attachment loss

Question 33

Miller Class II:

Answer 33

Marginal recession
extends to or beyond MGJ. No proximal
attachment loss.

Question 34

Miller Class III:

Answer 34

Marginal recession
extends to or beyond MGJ. Presence of
interproximal attachment loss.

Question 35

Miller Class IV:

Answer 35

Marginal recession
extends to or beyond MGJ. Severe
interproximal attachment loss.

Question 36

Autogenous Gingival Graft
* Techniques
(4)

Answer 36

– Free Gingival Graft
– Connective Tissue Graft
– Semi-lunar Coronally Positioned Flap
– Laterally Positioned Flap

Question 37

– Free Gingival Graft
* Miller’s Free Gingival Graft with use of —
* Holbrook’s Free Gingival Graft technique
with—

Answer 37

citric acid
“stretching” suture design

Question 38

Autogenous Gingival Graft
* Advantages
(2)

Answer 38

– Root coverage on single or multiple teeth?
– Abundant donor tissue available

Question 39

Autogenous Gingival Graft
* Disadvantages
(3)

Answer 39

– Color**
– Type of attachment?
– Second surgical site

Question 40

“Free” Gingival Graft
* Graft Thickness
(2)

Answer 40

–Primary contraction
–Secondary contraction

Question 41

“Free” Gingival Graft
* Variation in Technique

Answer 41

– Placement on bone results in less
mobility, less shrinkage, better
hemostasis, retarded healing

Question 42

“Free” Gingival Graft
* Clinical Technique: Recipient Site
(5)

Answer 42

–Anesthesia
–Incision (length and angle)
–Connective tissue bed preparation
–Fenestration (Optional)
–Hemostasis

Question 43

“Free” Gingival Graft
* Clinical Technique: Donor Site
(2)

Answer 43

–Measure required graft size and mark
if needed
–Remove graft from palate or other
area of attached tissue with scalpel or
graft knife

Question 44

“Free” Gingival Graft
* Clinical Technique: Immobilization
(3)

Answer 44

– Place graft in saline-soaked sponge
– Place first suture in graft (out of the
mouth).
– Place graft onto recipient site and suture
to immobilize the graft. (Suture at
coronal aspect.)

Question 45

“Free” Gingival Graft
* Graft Thickness
(2)
* Variation in Technique
(1)

Answer 45

–Primary contraction
–Secondary contraction

– Placement on bone results in less
mobility, less shrinkage, better
hemostasis, but slower healing time

Question 46

“Free” Gingival Graft
* Wound Healing
(5)

Answer 46

– Plasmatic circulation (2-4 days)
– Revascularization (2-8 days)
– Organic Union (4-10 days)
– Epithelialization (10-14 days)
– Keratinization (21-180 days)