Perio Plastics II

Question 1

Who classified clinical management of non-proximal recession defects?

Answer 1

Chambrone & Avila-Ortiz 2021

Question 2

What are the 3 Subtypes of the recession treatment classification based on?

Answer 2

Attached Gingiva and Gingival Thickness

Question 3

What is Subtype A?

Answer 3

_>_1mm AG

_>_1mm MT

Question 4

What is Subtype B?

Answer 4

_>_1mm AG

_<_1mm MT

Question 5

What is Subtype C?

Answer 5

_<_1mm AG

Question 6

What Tx options for Subtype A?

Answer 6

RT½: CAF or LPF (alternative: Bilaminar)

RT3: NOT RECOMMENDED

Question 7

What Tx options for Subtype B

Answer 7

RT½: Bilaminar (alternative LPF)
RT3: Bilaminar may be indicated

Question 8

What Tx options for Subtype C?

Answer 8

RT½: FGG (alternative: Tunnel/LPF)
RT3: FGG may be indicated

Question 9

What happens to KG with time after CAF? Why?

Answer 9

It increases - repositioning of the MGJ to its genetically pre-determined position (Zucchelli)

Question 10

Who first described CAF?

Answer 10

Bernimoulin 1975

Question 11

How much advancement do you need for CAF? Why? Citation?

Answer 11

Pini-Prato et al. 2005 (prospective)

2mm above CEJ was associated with 100% CRC

3mm recession required 2.5mm after logistic regression

More mm of coverage can be expected when treating a larger recession

1mm apical migration of MGJ after 6mo

Question 12

What rationale is there for CAF?

Answer 12

Root Coverage

Adequate KT apical to the root

Good OH

Maxillary anterior (more aesthetic)

Question 13

Whats the minimum flap thickness for CAF alone? Citation What if its less? Citation

Answer 13

0.8mm (Baldi et al. 1999)

then CAF+CTG have better outcome (Cairo 2016)

Question 14

What determines what kind of material you use?

Answer 14

Flap thickness!

Question 15

Where should flap thickness be measured?

Answer 15

2mm below the gingival margin

Question 16

How wide should the surgical papilla be and how far from the peak of the anatomical papilla? (Citation)

Answer 16

3mm wide

X (recession depth) +1

Zucchelli et al. 2007

(Wang says it was him)

Question 17

What is the rationale behind split-full-split?

Answer 17

Makes use of the periosteum to cover the denuded avascular root surface

Question 18

What is the Pro/Con of a triangular incision for CAF? When should you use it? Citation

Answer 18

Trapezoidal has more keloid formation

Triangular is more technique sensitive

When there is not 3mm interproximally for the surgical papilla width

Zucchelli et al. 2016

Question 19

What article compared CAF vs CAF+CTG?

Answer 19

Cairo et al. 2016

Question 20

How does CAF compare to CAF+CTG? Citation

Answer 20

32pts - RCT - 1yr FU

In GT <0.8mm CAF+CTG >> CAF alone

CAF higher esthetic score in thick gingiva

Cairo et al. 2016

Question 21

What was the first form of tunneling? Describe it Citation

Answer 21

the Semilunar incision

Semilunar incision parallel to gingival margin - split thickness apically

no sutures

Tarnow 1986

Question 22

Who described the lateral sliding flap/modification?

Answer 22

Grupe 1956

Grupe 1966

Question 23

What are indications/drawbacks to the Lateral Sliding Flap? How does the modification help with the drawback?

Answer 23

Ideal for isolated gingival recessions

Better esthetic vs FGG

Recession at the donor site!

Modification allows 3mm apical to donor margin to avoid recession

Question 24

Who first described the double papilla flap?

Answer 24

Cohen & Ross 1968

Question 25

Who developed the Envelope flap?

Answer 25

Raetzke 1985

Question 26

What is the Envelope flap?

Answer 26

Partial thickness around the defect Graft placed like a tunnel with middle exposed Middle retains epi

Question 27

What are clinical benefits of FGG vs APF?

Answer 27

FGG increases both KTW and Thickness vs APF

Question 28

How does placing FGG on Bone vs Periosteum effect the outcome? CitationS

Answer 28

Dordick et al. 1976 FGG on bone: no mobility - less swelling BUT 2 week “lag” in healing vs periosteum Less shrinkage on bone (James et al. 1978)

Question 29

What is a big advantage of using autogenous tissue?

Answer 29

Creeping Attachment

Question 30

What cells do Autogenous Grafts contain? What does this provide?

Answer 30

Keratinocytes and Fibroblasts Creeping Attachment

Question 31

What flaps maintain their blood supply specifically?

Answer 31

CAF, Double Papilla, Lateral Sliding, Envelope, Semilunar

Question 32

What does graft survival depend on for free grafts? why? Citation

Answer 32

Close adaptation to the recipient bed - facilitates revascularization (Yu et al. 2018)

Question 33

How does esposing some of a CTG effect the outcome? Citation

Answer 33

Exposed site will gain KT Covered cites will provide more recession reduction Dodge et al. 2018

Question 34

What phases of contraction are there for FGG? What is responsible for each? Citation

Answer 34

Primary and Secondary Primary: due to amount of elastic fibers in graft Secondary: cicatrization between graft and recipient bed Sullivan & Atkins 1968

Question 35

How does graft thickness effect FGG shrinkage?

Answer 35

Thicker grafts have less secondary contraction

Question 36

How thick should an FGG be to avoid pain?? citation

Answer 36

_\<_2mm (Burkhardt et al. 2015) Residual tissue thickness of _\>_2mm = less post op pain (Zucchelli et al. 2010)

Question 37

How thick do classic studies say an FGG should be? How thick do we do?

Answer 37

0.75-1.25mm (Soehren et al. 1973) 1-1.5mm

Question 38

Rationale for FGG

Answer 38

increase KT, AG, Vestibular depth, and increase tissue thickness

Question 39

how do FGG perform long term?

Answer 39

4.2mm increase in KT after 1yr 0.7mm decrease after 10-25yrs Aguido et al. 2008

Question 40

Who developed the 2 step approach?

Answer 40

Bernimoulin et al. 1975

Question 41

When would you consider a 2 step approach instead of a CTG?

Answer 41

Shallow vestibule non-esthetic zone NO KT

Question 42

How much creeping attachment can we expect with CTG?

Answer 42

0.89mm but depends on: Width of recession (narrow\>wide - 3mm) Position of graft (over denuted surface) Bone resorption Position of tooth Hygene **From 3mo - 1yr** Matter & Cimasoni 1976

Question 43

What is the benefit of a De-Epithelialized CTG vs sCTG?

Answer 43

less fatty/glandular tissue

Question 44

How does sCTG compare to De-epiCTG? Citation

Answer 44

NSSD in post-op pain or root coverage outcomes (Zucchelli et al. 2010) More GT with De-epiCTG !!! (Less graft shrinkage)

Question 45

How can you help attain hemostasis from donor site?

Answer 45

Collatape, Gelfoam, ozone therapy, Oxidized cellulose

Question 46

Who developed tunneling?

Answer 46

Zabalegui et al. 1999

Question 47

How does Tunneling compare to CAF? Citation

Answer 47

Tavelli et al. 2018 Systematic review/meta analysis Similar outcomes **CAF \> TUN when same material compared**

Question 48

Who developed the VISTA approach? What is it?

Answer 48

Zadeh 2011 Tunnel with a VR in the mucosa for better access used COMPOSITE to maintain sutures coronally rhPDGF+B-TCP

Question 49

When treating multiple recessions, where should you suture first?

Answer 49

Periphery stabilized, the suture toward the center of the flap

Question 50

How much coronal advancement should we gt for CRC? citation

Answer 50

2mm above CEJ (Pini Prato et al. 2005)

Question 51

What type of sutures are used for fixing pedicle flaps?

Answer 51

Interrupted and Suspensory (Sling/Double Sling)

Question 52

What kind of healing takes place histologically with diffferent procedures? citation

Answer 52

Zucchelli & Mounssif 2015 for CAF, CAF+CTG, and FGG New connective tissue Long junctional epithelium

Question 53

Who researched healing of Lateral Pedicle flap?

Answer 53

Wilderman & Wentz 1965

Question 54

Healing of Lateral Pedicle Flap

Answer 54

Adaptation (0-4) Proliferation (4-21) Attachment (27-28) Maturation Wilderman & Wentz

Question 55

Who researched healing of CTG?

Answer 55

Guiha et al. 2001

Question 56

Healing of CTG

Answer 56

Day 7: Blood vessels from both sides of graft Day 14: Complete vascularization of graft Day 28: JE formed Day 28-60: Normal vascularization/oral epithelium

Question 57

How much CTG can be exposed? itation

Answer 57

30% Guiha et al. 2001

Question 58

Where do vessels come from to supply CT Graft?

Answer 58

Periodontal plexus Supraperiosteal Plexus Flap (subepithelial/crevicular plexuses)

Question 59

Who studied the healing of FGG?

Answer 59

Oliver 1968

Question 60

Healing of FGG

Answer 60

0-3: Initial (Plasmatic Circulation) 4-11: Revascularization 11-42: Maturation

Question 61

How doe primary contraction impact the graft healing?

Answer 61

Shrinkage due to the amount of elastic fibers which causes vessel collapse and delays graft vascularization

Question 62

What is the Cairo esthetic score?

Answer 62

1: Gingival Margin level 2: Marginal contour 3: Tissue Texture 4: MGJ Alignment 5: Gingival color

Question 63

What options are there for papilla reconstruction?

Answer 63

Envelope Vertical tissue growth with Tuberosity

Question 64

Classification of gingival recession around implants (Classes)

Answer 64

Zucchelli 2019 CIass I: No recession - only color change - good implant position Class II: Some mid-facial recession - no papilla recession (facial of crown is slightly palatal) Class III: Papilla loss - good implant position Class IV: Papilla loss - poor implant position

Question 65

Classification of gingival recession around implants (Subclasses)

Answer 65

Tip of papilla to Gingival Margin ``` Subclass A: Both papilla _\>_3mm Subclass B: at least 1 papilla is 1-3mm Subclass C: at least 1 papilla is \<1mm ```

Question 66

When can you expect creeping attachment?

Answer 66

In Narrow Deep defects