Characteristics of the healthy attached gingiva

Colour Contour of the papillae Contour of the gingival margin Outline translucency Texture Width of the gingiva propria Depth of the vestibulum

BIOTYPE

Periodontal biotypes

Narrow, thin, scalloped Susceptible to recession

Thick, plain Susceptible to cicatrization

Ohlson M, Lindhe J. Periodontal characteristics in individuals with varying forms of the upper central incisors. J Clin Periodontol 1991;18:78-82

Parodontlis korrekcis

mtti technikk

THE TYPES AND FORMS OF GINGIVAL RECESSION

NYRECESSIO TPUSAI

ALVEOLAR BONE

Etiology of gingival recession

Baseline measurements
Individual biotype has to be recorded first
Gingival recessions Depth - GRD Gingival recessions Width - GRW Keratinized Gingival width - KG Papilla-Contactpoints distance - PC Probing depth - PD KG Plaque index- PI Gingival index -GI GRW
GRD

. .

PD

PC

Classification

Miller P.D. A classification of marginal tissue recession Int. J. Periodontics Dent. 1985;5(2):8-13

I.

III.

II.

IV.

MILLERS CLASSIFICATION
Class I

The recession does not affect the interdental papilla and does not extend to the mucogingival junction . The recession does not affect the interdental papilla but extends to the mucogingival junction The recession affects the interdental papilla The recession seriously affects the interdental papilla.

Class II

Class III Class IV

Miller classification of gingival recessions

Class 1 : Marginal tissue recession that does not extend to
the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be narrow or wide (group 1 and 2 Sullivan and Atkins classification).

Prognosis: good to excellent

Miller classification of gingival recessions

Class 2: Marginal tissue recession that extends to or
beyond the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be subclassified into wide and narrow (corresponding to group 3 and 4 Sullivan and Atkins classification).

Prognosis: good to excellent

Miller classification of gingival recessions

Class 3: Marginal tissue recession that extends to or
beyond the mucogingival junction, in addition, there is bone and/or soft tissue loss interdentally or malposition of the tooth.

Prognosis: only partial coverage can be expected.

Miller classification of gingival recessions

Class 4: Marginal tissue recession that extends to or
beyond the mucogingival junction with severe bone loss and soft tissue loss interdentally and/or severe tooth malposition.

Prognosis: very poor with current techniques

Lang and Le based on a study done on dental students postulated that minimum 2 mm keratinized gingiva can maintain gingival health even in adequate oral hygiene According to Corn (1962) only a 3 mm band of attached gingiva can guarantee the gingival and periodontal healthy .
Lang and Le. The Realtionship between the Width of the Keratinizated Gingiva and the Gingival Health. Journal of Periodontology 1972; 43; 623-627.

Wennstrm and Lindhe (1988) showed in their animal study that thinner gingival margin associated with more severe microscopic inflammatory reaction that the thick well attached gingiva .Wennstrm,J.L. and Lindhe, J. Plaque induced gingival
inflammation in the abscence of attached gingiva in dogs. Journal of Clinical Periodontology 1983; 10: 266-276.

Dorfman and Kennedy (1980) based on their follow-up study came to a conclusion that though free gingival grafting is a successful and predictable surgical procedure it has no effect on the periodontal state and prognosis of periodontal disease
Dorfman, H. S., Kennedy J.S. Longitudinal evaluation of free autogenous gingiva grafts. Journal of Clinical Periodontology 1980; 7: 316-324.

The thin and narrow band of gingiva not necessarily provides less protection to the underlying periodontium that the thick and wide gingiva Though the 3 mm wide attached gingiva clinically creates a more favorable environment to the periodontium

The thin and narrow band of gingiva not necessarily provides less protection to the underlying periodontium that the thick and wide gingiva. Though the 3 mm wide attached gingiva clinically creates a more favorable environment to the periodontium

Different therapeutical options for root coverage localized defects

Pedicle flaps
Rotating flap Sliding flap

Free connective tissue grafts

epithelialized graft Subepithelial connective tissue graft

GTR-techniques
Resorbable and non-resorbable membranes

Bioactive agents (in combination with different flaps)

EMD ADM PRF

Development of different surgical techniques for mucogingival recessions

Frenulotomy Hirschfeld 1939 Guidelines for mucogingival surgery Friedmann 1957

Rotated and slided pedicle flaps

Laterally repositioned flap Grupe J. & Warren R. 1956 Laterally repositioned partial thickness flap Stafileno H. 1964 Oblique rotated flap Pennel BM Higgason JD, Towner JD, King Ko, Fritz BD, Salder JF. Oblique rotated flap. J periodontol. 1965 jul-aug;36:305-9 Laterally reposition flap with submarginal incision Grupe HE. 1966 Modified technique for the sliding flap operation. J Periodontol. 1966 Nov-Dec;37(6):491-5. Double papillae repositioned flap Cohen DW 1968 Half-Moon shaped coronally repositioned flap Tarnow DP. 1986

Periodontal Plastic Surgery /PPS/

Augmentation of keratinized gingiva Coverage of denuded root surfaces Reconstruction of papillae Augmentation or correction of periimplant mucosa Crown lengthening Gingival preservation of teeth in ectopic position Removal of aberrant frenulum /Frenulectomy/ Preservation of fresh extraction sites Hard and soft tissue augmentation of edentulous ridges

Esthetic (Periodontal) Reconstructive surgery

Development of different surgical techniques for mucogingival recessions

Frenulotomy Hirschfeld 1939 Guidelines for mucogingival surgery Friedmann 1957

Rotated and slided pedicle flaps

Laterally repositioned flap Grupe J. & Warren R. 1956 Laterally repositioned partial thickness flap Stafileno H. 1964 Oblique rotated flap Pennel BM Higgason JD, Towner JD, King Ko, Fritz BD, Salder JF. Oblique rotated flap. J periodontol. 1965 jul-aug;36:305-9 Laterally reposition flap with submarginal incision Grupe HE. 1966 Modified technique for the sliding flap operation. J Periodontol. 1966 Nov-Dec;37(6):491-5. Double papillae repositioned flap Cohen DW 1968 Half-Moon shaped coronally repositioned flap Tarnow DP. 1986

FRENULECTOMIA

Laterally repositioned flap

Grupe J. & Warren R. Repair of gingival defects by a sliding flap operation. J Periodontol 1956 27, 290-295 Stafileno H. Management of gingival recession and root exposure problems associated with periodontal disease. Dental Clinics of North America 1964 March 111-120

Laterally positioned flap It was first described by Grupe and Warren (1956) the principle of the surgical technique was to cover the denuded root surface with the laterally sliding full thickness flap prepared from the attached gingiva of the distal teeth This technique was modified and improved by Staffelino (1964), and Pfeifer & Heller (1971). According to them only a partial thickness flap was prepared to facilitate the postoperative healing and to avoid the postoperative bone resorption and gingival recession at the donor site.

Laterally rotated flap

MILLER CLASS II GINGIVAL RECESSION AT TOOTH # 14 WAS COVERED BY A PARTIAL THICKNESS FLAP PREPARED FROM THE GINGIVAL OF THE 2nd PREMOLAR AND 1st MOLAR

EXTENDED LATERALLY POSITIONED PEDICLE FLAP

LATERALLY POSTIONE FLAP COMBINED WITH FREE AUTOGENOUS GINGIVAL GRAFT

LATERALLY POSTIONE FLAP COMBINED WITH FREE AUTOGENOUS GINGIVAL GRAFT

Double papilla flap procedure

Cohen DW, Ross SE. The double papillae repositioned flap in periodontal therapy. J Periodontol. 1968 Mar;39(2):65-70.

Half-Moon shaped coronally repositioned flap

Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol. 1986 Mar;13(3):182-5.

Half-Moon shaped coronally repositioned flap

Coronally advanced flap

Brustein DD. Cosmetics Periodontics- Coronally repositioned pedicle graft. Dent.Surv. 1970;46:22-25. Allen EP,Miller PD. Coronal positioning of existing gingival.Short term result in the treatment of shallow marginal tissue recession. J Periodontol 1989;60:316-319.

Coronally advanced flap

Coronally advanced flap

EPITHELIALIZED FREE GINGIVAL GRAFT

VESTIBULOPLASTY WITH FREE GINGIVAL GRAFT

1. free gingival graft 2. minor salivary glands 3. Arteria palati 4. Vena palati 5. Rugae palati

THE SURGICAL TECHNIQUE OF THE EPITHELIALIZED FREE GINGIVAL GRAFTING

FREE GINGIVAL GRAFTS

Nabers J.M. Free gingival grafts. Periodontics 1966;4: 243-245.

PREOP

POSTOP

PREOP

POSTOP

HEALING AFTER GRAFTING

Initial phase (0-3. days) Revascularisation (2-11. days) Maturation (11-42.days)

Oliver R. at al Microscopic evaluation of healing and revascularisation of free gingival grafts. J. of Periodont. Res. 1968;3: 84-95. Nobuto T. et al Microvascularisation of the free gingival autograft. J. of Periodont Res. 1988;59: 639-646.

THE EPITHELIALIZED FREE GINGIVAL GRAFT IS ALWAYS WHITER AND PALER THAN THE NEIGHBORING TISSUES

ORTHODONTIC TREATMENT

DENTAL IMPLANT

FREE GINGIVAL GRAFT 25 YEARS AFTER SURGERY

A SZABAD NYLEBENY 25 VVEL A MTT UTN

FREE GINGIVAL GRAFT 25 YEARS AFTER SURGERY

MILLER II- III GINGIVAL LAESION

EPTHELIALIZED FREE GINGIVAL GRAFT FROM THE PALATE

DURING HEALING THE EPITHELIA TOTALLY DESQUAMATED BUT LATER REEPITHELIALIZED FROM THE MARGINS

2001 NOVEMBER

2012 MJUS

MILLER II-III LAESION

2 YEARS CONTROL

CLINICALLY SUCCESSFUL BUT AESTHETICALLY QUESTIONABLE RESULTS IN THE HIGHLY VASCULARIZED RECIPIENT NEIGHBORHOOD

MARKED POSTOPERATIVE CREAPING ATTACHMENT WITHIN TWO YEARS

1980 free gingival graft

2000 exostosis