4. Periodontal Plastic
Surgery
• Defined as the surgical procedures
performed to correct or eliminate anatomic,
developmental, or traumatic deformities of
the gingiva or alveolar mucosa.
5.
6.
7. Recession Prevalence and Age
58
41
22
13
6
0
15
30
45
60
75
1 2 3 4 5
Prevalence of Recession % In US >30
18
30
40
46
60
0
15
30
45
60
75
40 50 60 70 80
Recession Prevalence (%) by Age
Recession (mm) Age
60% of 80 year olds have recession58% of population have at
least 1mm of recession
8. Why is Prevalence of Recession
Important?
• Since sites with previous recession are prone to
additional recession, the aging U.S. population may have
a large number of sites that need root coverage grafting.
9. “Increase in gingival thickness will help prevent future
recession in patients with a thin periodontal phenotype”
1. Prevention:
• restoring or increasing marginal width of
keratinized gingiva and/or marginal soft
tissue thickness
may offer increased resistance to further
recession caused by inflammation secondary to
plaque (weak evidence )
Purposes of Treating Recession
10. 1. Prevention:
• restoring or increasing marginal width of
keratinized gingiva and/or marginal soft
tissue thickness
may offer increased resistance to further
recession caused by inflammation secondary to
plaque (weak evidence)
may guard against factitial injury (faulty
toothbrushing) (weak evidence)
pre-prosthetically may protect against iatrogenic
dentistry (ie. invading biologic width) (weak
evidence)
may offer “protection” to the alveolar bone from
resorbing as a result of all of the above (weak
evidence)
Purposes of Treating Recession
11. 1. Prevention:
• restoring or increasing marginal width of
keratinized gingiva and/or marginal soft
tissue thickness
prior to orthodontic treatment may prevent or
minimize the formation of a dehiscence (strong
evidence)
Purposes of Treating Recession
12. Purposes of Treating Recession
2. Root coverage:
• bridging the soft tissue fenestration with
either keratinized or non-keratinized
gingiva
reduce risk of root caries (strong evidence)
reduce root sensitivity following abrasion,
erosion, abfraction or prior to tooth bleaching
(strong evidence)
13. Purposes of Treating Recession
2. Root coverage:
• bridging the soft tissue fenestration with
either keratinized or non-keratinized
gingiva
improve esthetics (very strong evidence)
Pre-prosthetically
• prior to crown placement or class V restoration enabling
the clinician to control the incis-ogingival dimension of
the crown/restoration and to make crown/restoration
height compatible with the height of the adjacent teeth
• prior to porcelain veneer placement can eliminate the
difficult task of bonding to cementumb
14. Purposes of Treating Recession
2. Root coverage:
• bridging the soft tissue fenestration with
either keratinized or non-keratinized
gingiva
improve esthetics (very strong evidence)
Post-prosthetically
• may be used to satisfy esthetic requirements such as
exposed crown margins or exposed implant abutments
eliminating the need to replace existing crowns
15. • In medicine, prevention is any activity
which reduces the burden of mortality
or morbidity from disease (recession).
This takes place at primary,
secondary and tertiary prevention
levels.
PREVENTION
16. Primary Prevention
• Primary prevention avoids the
development of a disease.
• Most population-based health promotion
activities are primary preventive measures.
– ie. educating patients on good oral hygiene
and an appropriate tooth brushing technique
can prevent soft tissue recession
17. Secondary Prevention
• Secondary prevention activities are aimed at
early disease detection, thereby increasing
opportunities for interventions to prevent
progression of the disease (further recession)
and emergence of symptoms (ie. root sensitivity,
caries).
– Periodic evaluation of a patients’ periodontium
including documenting changes in marginal soft tissue
health compared to initial baseline values (first visit “x”
years/months ago) using periodontal charting and
“clinical photos”
18. Tertiary Prevention
• Tertiary prevention reduces the negative
impact of an already established disease
by restoring function and reducing disease-
related complications (ie. root sensitivity,
caries).
– Treating recession with Auto/Allo STG and/or
PF (CAF, LSF)
19. First step in treating recession defect(s) is
to identify the etiology and correct it !
• What Caused the Gingival Recession?
– Tooth malposition
• (rotated, tilted, facially displaced teeth)
– Faulty tooth-brushing technique
– Gingival inflammation
– Abnormal frenum attachment
– Iatrogenic dentistry (tooth preparation, margin
placement, impression taking)
– Occlusion? (weak controversial evidence)
20. Sullivan & Atkins, Per 68
• shallow or deep
• narrow or wide
• shallow-narrow, shallow-wide
• deep-narrow, deep-wide
21. Miller PD, IJPRD 85
• Class 1: REC not to MGJ, no IP bone or
papilla loss, 100% coverage
• Class 2: REC past MGJ, no IP bone or
papilla loss, 100% coverage
• Class 3: REC past MGJ, IP bone or
papilla loss, malposition, partial coverage
• Class 4: REC past MGJ, severe IP bone
or papilla loss, malposition, no coverage
22. All STG heal by New Attachment
• The union of connective tissue or
epithelium with a root surface that has
been deprived of its original attachment
apparatus. This new attachment may be
epithelial adhesion and/or connective
tissue adaptation or attachment and may
include new cementum
23. ROOT COVERAGE PROCEDURES
1. Pedical flap (repositioning of “adjacent” attached
gingiva)
• Laterally positioned (AKA repositioned) flap
• Coronally positioned (AKA repositioned) flap
2. Coronal advancement of previously placed free gingival
grafts
3. Gingival grafts placed directly over the root surface
4. Gingival grafting performed in conjunction with flap
advancement for submersion (SECT graft)
5. Guided Tissue Regeneration (GTR)
24. ROOT COVERAGE PROCEDURES
1. Pedical flap (repositioning of “adjacent” attached
gingiva)
• Laterally positioned (AKA repositioned) flap
• Coronally positioned (AKA repositioned) flap
• When adequate adjacent gingiva exists, repositioning it over
the denuded root surface provides the most esthetic result!
29. Cicatrization of the Free Connective
Tissue Graft
Cicatrization: To heal or become healed by the formation of scar tissue.
30.
31. ROOT COVERAGE PROCEDURES
4. Gingival grafting performed in conjunction with flap advancement
for submersion
• Adequate gingiva does not always exist in adjacent locations,
therefore grafting of gingiva from a remote location is often
required to augment the area
34. ROOT COVERAGE PROCEDURES
4. Gingival grafting performed in conjunction with flap advancement
for submersion
• Adequate gingiva does not always exist in adjacent locations,
therefore grafting of gingiva from a remote location is often
required to augment the area
35. Subepithelial Connective Tissue Graft
Technique for Root Coverage by Langer
and Langer (1985)
A horizontal incision is
placed at the level of
the cementoenamel
junction of both teeth.
This is connected to
vertical incisions on
either side.
36. Subepithelial Connective Tissue Graft
Technique for Root Coverage by Langer
and Langer (1985)
A partial thickness flap
is elevated. Care is
taken to preserve the
periosteum apical to the
area of recession. The
flap is elevated to the
mucobuccal fold.
Convexities on the
denuded roots are
flattened with curettes.
37. Subepithelial Connective Tissue Graft
Technique for Root Coverage by Langer
and Langer (1985)
A view of the palate
showing the donor site.
Two horizontal incisions
are placed 2 to 3 mm
apical to the free gingival
margin. These are
connected by vertical
incisions which facilitate
flap elevation and
connective tissue graft
removal.
38. Subepithelial Connective Tissue Graft
Technique for Root Coverage by Langer
and Langer (1985)
The donor tissue is
placed directly over
the denuded area.
The size of the graft
permits it to extend
onto the remaining
periosteal covering on
the nondenuded
portion of both teeth.
This will help supply
circulation to the
donor tissue.
39. Subepithelial Connective Tissue Graft
Technique for Root Coverage by Langer
and Langer (1985)
The donor connective tissue
and epithelium are sutured to
the underlying connective
tissue interproximally. The
recipient flap is then sutured
directly over the graft. If
possible, the flap is pulled
over a major portion of the
graft to ensure temporary
nourishment with an
additional source of
circulation.
40. ROOT COVERAGE PROCEDURES
4. Gingival grafting performed in conjunction with flap advancement
for submersion
• Adequate gingiva does not always exist in adjacent locations,
therefore grafting of gingiva from a remote location is often
required to augment the area
41. Connective Tissue Graft Using an
Envelope Flap by Raetzke (1985)
Perform root
planning of the
exposed root and
use a finishing bur
to recontour it.
43. Connective Tissue Graft Using an
Envelope Flap by Raetzke (1985)
Connective tissue is
placed in envelope
flap.
44. Connective Tissue Graft Using an
Envelope Flap by Raetzke (1985)
Cover the exposed
root with the
connective tissue graft
and perform
compressive
hemostasis. No suture
is required.
Cyanoacrylate may be
used to hold the graft.
45. Connective Tissue Graft Using an
Envelope Flap by Raetzke (1985)
• Advantages of this technique include minimal
trauma to both donor and recipient sites with
rapid healing, favorable healing over wide and
deep areas of recession, and excellent esthetic
results.
• A disadvantage is that the envelope flap cannot
be displaced coronally.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62. ROOT COVERAGE PROCEDURES
4. Gingival grafting performed in conjunction with flap advancement
for submersion
• Adequate gingiva does not always exist in adjacent locations,
therefore grafting of gingiva from a remote location is often
required to augment the area
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76. ROOT COVERAGE PROCEDURES
4. Gingival grafting performed in conjunction with flap advancement
for submersion
• Adequate gingiva does not always exist in adjacent locations,
therefore grafting of gingiva from a remote location is often
required to augment the area
88. The Connective Tissue and Partial
Thickness Double Pedicle Graft by Harris
(1992)
• The greatest advantage of this technique is that
a pedicle graft can cover connective tissue
grafts on root surfaces lacking a vascular
supply.
• In addition to root coverage, the width of
keratinized gingiva can be increased.
Therefore, this technique may be used in areas
of gingival recession with narrow keratinized
gingiva.
89. ROOT COVERAGE PROCEDURES
4. Gingival grafting performed in conjunction with flap advancement
for submersion
• Adequate gingiva does not always exist in adjacent locations,
therefore grafting of gingiva from a remote location is often
required to augment the area
90. TRADITIONALLY
• Augmentation of the gingival complex at
the time of root coverage has been
performed with autogenous connective
tissue (CT) harvested from the palate or
edentulous ridge.
91. Limitations of autogenous CT grafts which
have led to the search for non-autogenous
substitutes for palatal tissue
• Second surgical site morbidity
• Limited available quantity
92. Care must be taken not to damage the
palatine artery.
• Potential Intra-operative bleeding
95. FGG Shrinkage
• Ward: 47% of A-C width
• Rateitschak: 25% of A-C width
• Soehren: 30% of A-C width
• James, McFall: 1.5 to 2X more if on periosteum instead of bone
• Mormann, JP 81:
– Very thin, 45%
– Thin, 44%
– Intermediate, 38%
– If taken with scalpel 30%
• Rossman, Rees: 24% of graft surface area
• Wei: 16%
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107. Creeping Attachment
• Matter (1980) described a phenomenon of
additional root coverage during healing
which may be observed between 1 month
and 1 year post-grafting. He reported an
average of 1.2 mm of coronal creep at 1
year with no additional change.
108. Acellular Dermal Regenerative Tissue
Matrix (ADM) Defined
ADM is an acellular dermal matrix derived from
donated human skin tissue supplied by US AATB-
compliant tissue banks utilizing the standards of
the American Association of Tissue Banks
(AATB) and Food and Drug Administration's
(FDA) guidelines. Since ADM is regarded as
minimally processed and not significantly changed
in structure from the natural material, the FDA has
classified it as banked human tissue.
109. What is Acellular Dermal Regenerative
Tissue Matrix?
• A human soft tissue
• Used in various applications
since 1995
–Burns
–Head and Neck
Reconstructions
–Dental, 1997
–Urology – bladder slings &
pelvic floor reconstruction
–Orthopedics – rotator cuff
repair & periosteal
replacement
–Hernia repair
111. ADM – Safe Tissue
» Over 13 years
» Over 900,000 cases
Safe History
112.
113.
114.
115.
116.
117.
118. Procurement of Alloderm
• AlloDerm is a processed tissue that comes from
donors who are extensively screened and tested
for presence of diseases including HIV and
hepatitis. The processing procedure has been
demonstrated to reduce HIV and hepatitis C
surrogate virus to non-detectable levels.
Additional testing for presence of pathogens is
performed prior to and following processing to
ensure that Alloderm is disease-free before
release for patient care.
119. Processing of Alloderm
• A buffered salt solution removes the
epidermis, and multiple cell types within
the dermis are then solubilized and
washed away using a patented series of
non-denaturing detergent washes that
rapidly diffuse into the dermis.
120. ADM Processing
• Acellular Dermal Matrix is of human
origin.
• It has been especially processed to
remove both the epidermis and the cells
that can lead to tissue rejection and graft
failure, without damaging the matrix.
• The processed tissue matrix is preserved
with a patented freeze-drying process that
prevents damaging ice crystals from
forming.
121. Regenerative Tissue Martix
The processed regenerative human
tissue matrix is then preserved using
LifeCell’s patented amorphous freeze-
drying process, thereby retaining the
critical biochemical and structural
components needed to maintain the
tissue’s natural regenerative
properties. The matrix has a two-year
shelf life.
Cryopreservation
124. ADM works like an Autograft
Provides a bioactive matrix consisting
of collagens, elastin, blood vessel
channels, and bioactive proteins that
support natural revascularization, cell
repopulation, and tissue remodeling.
125. Healing by “Repair” (fibrous encapsulation)
or “Regeneration” (incorporation)
Inflammation Matrix & Stem Cells
Scar Tissue Normal Tissue
Fibrosis
Intrinsic Tissue
Regeneration
Process
126. Regenerative Tissue Matrix
Unique Outcome
Rapid revascularization
and repopulation
The vascular architecture is
endothelialized, and host stem
cells migrate and bind
specifically to protein
components of the matrix.
Host cells respond to the
three-dimensional architecture
and adapt to the local
environment.
127. Regenerative Tissue Matrix
Remodeling to the patient’s
own tissue
The matrix is now fully
revascularized,
repopulated and
integrated into the host
tissue. Proteins undergo
normal breakdown and
regeneration.
Unique Outcome
128. Regenerative Tissue Matrix
Transitioning into
the host tissue
Host cells continue to respond
to the local environment, and
the matrix transitions into the
tissue it is replacing at the site
of the transplant.
Unique Outcome
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
139.
140.
141.
142. Advantages of ADM
1. Equivalent to “gold standard”
– Provides effective and predictable root coverage
compared to connective tissue
2. Unlimited supply
– Multiple sites can therefore be treated with a single
procedure (sextant, quadrant, full arch)
3. Excellent tissue color match obtained as the
graft is repopulated with the recipient’s cells
and the final gingival color exactly matches the
recipient’s pre-treatment gingiva
143.
144.
145. #1/2 Orban DE Knife, Modified
Modified with a flattened surface on one side and a domed surface on the other, plus a reduced cutting edge
at the shank. Ideal for intrasulcular sharp, supraperiosteal dissection. Used after the initial blunt dissection (using
the HF-PPAEL or HF-PPAELA) to complete the preparation of the pouch recipient site. The flat side is positioned
against the bone and the domed side faces the soft tissue facilitating dissection without perforation. Reduced
cutting surface lessens the possibility of inadvertently incising the pouch margin during dissection.
146. Allen Micro Periosteal Elevator
Designed for elevation of a mucoperiosteal pouch with an intrasulcular approach (following an
intrasulcular incision from the base of the sulcus to the alveolar crest). May be used with the curve
angled inward as well as outward. Especially useful for papilla elevation using the curved end angled
outward. Also placed between the pouch and the graft to prevent needle penetration of the graft
during suturing.
147. Allen Micro Periosteal Elevator, Anterior
Similar in design but smaller than the HF-PPAEL (above), with a reduced curvature.
Designed for use in the mandibular anterior region where the tooth diameter is smaller. It
is also useful in more delicate dissections where the tissue is thin and/or the bony
topography is irregular.
148. #7/8 Younger-Good Curette, #6 Handle
Used for root planing prior to root coverage grafting. Also used for passing the AlloDerm
into the tunnel.
151. Micro Non-Serrated Castroviejo Perma Sharp 7” Str. Round Handle
A smaller diameter jaw allows retrieval of the needle tip in tight quarters. For use with 6-0
and smaller sutures.
153. ADM and the Alternate Papilla Tunnel
Technique
1. Local anesthetic by local infiltration using Lidocaine
1:100, 000 epi.
2. Root planing with #7/8 younger good curette to
remove any existing resin or irregularities in root
suface assuring the line angles of the root surface are
smooth as they meet the buccal surfaces.
– Root planing is “A definitive treatment procedure designed
to remove cementum or surface dentin that is rough,
impregnated with calculus, or contaminated with toxins or
microorganisms.
3. Interproximal flossing of teeth
154. EDTA
Dentinal surface of a sample covered
with debris and smear layer. SEM
1500X magnification.
Dentinal surface of a sample covered
with less than 25% debris. SEM 1500X
magnification.
30-60
sec.
4. Application of a chelating agent EDTA
(Ethylenediaminetetracetic acid) for 30-60 sec with cotton tip
applicator to remove smear layer and produce canals with
patent dentinal tubules obstructed by root planing; this doesn’t
harm blood supply of marginal tissue due to neutral pH
ADM and the Alternate Papilla
Tunnel Technique
155.
156. ADM and the Alternate Papilla Tunnel
Technique
5. Alternating papilla are incised
6. Split thickness dissection is performed to
create a pouch adjacent to involved teeth
using the flat side of a modified #1/2 Orban DE
knife which is positioned against the bone and
the domed side faces the soft tissue facilitating
dissection without perforation
157.
158.
159.
160. ADM and the Alternate Papilla Tunnel
Technique
7. Remove from outer foil pack and drop graft
into saline bath directly from inner package.
161. Important:
Before use, clinicians should review
all risk information, which can be
found on the packaging and in the
“Information for Use” attached to
the packaging of each AlloDerm
graft.
162.
163. ADM and the Alternate Papilla Tunnel
Technique
8. Re-hydrate in two consecutive 10-20 minute sterile saline
baths.
9. Remove paper backing from AlloDerm between first and
second baths.
164.
165. ADM and the Alternate Papilla Tunnel
Technique
8. ADM is secured against the buccal root
surface(s) with 7.0 Polypropylene interupted
sling sutures with all knots placed on palatal
margins
166.
167. ADM and the Alternate Papilla Tunnel
Technique
5. Flaps/pouch are coronally advanced over the
graft with 6.0 Polypropylene interupted sling
sutures with all knots placed on palatal margins
168.
169. When performing a CAF + ADM, the following measures have to
be taken to prevent flap retraction and exposure of the ADM as
described by Bernimoulin et al.
• A double sling suture (as described by
Dodge et al.)
170. Overcorrect for more severe
recession defects by 1mm when
using CAF because there is no
creeping attachment
• Pini Prato et al.
171. Post-op Medications
1. Analgesics
• non-steroidal anti-inflammatory agents
• steroids (ie. methylprednisolone )
2. Doxycyclin Hyclate (ie. Peridex®)
3. NO ANTIBIOTICS
• RISK OF INFECTION POST PERIODONTAL
SURGERY IS LESS THAN 1%
(Pack and Haber)
I’ll begin with a quick definition of AlloDerm and then we will proceed with all the particulars.
Lifecell introduced AlloDerm to the medical community in 1995 for burn patients. Since that time, the Regenerative Tissue Matrix has been used in many other areas of medicine, as you will see on the next slide. We started using AlloDerm in periodontal dentistry in 1997 and now have expanded into Guided Bone Regeneration.
AlloDerm and its sister products have a multitude of uses both in medical and dental.
With more than 800,000 successful implants and grafts to date, AlloDerm supports rapid revascularization, remodeling and transition to specific host tissue…resulting in tissue replacement that looks, acts, and responds like the original. There has been no reported viral transmission in 10 years of use in more than half-million grafts. As we learned earlier, recipients since 1995 include immunocompromised patients such as burn, pediatric, and geriatric.
The processed Regenerative human Tissue Matrix is then preserved by freeze-drying. This patented freeze-drying process prevents damaging crystal formation, therefore retaining the critical biochemical and structural components needed to maintain the tissue’s natural regenerative properties.
When water freezes, it expands because of ice crystal formation
This damages the matrix components
Soaking tissue in LifeCell’s cryoprotectant prevents ice crystal formation during the freeze-drying process
Left picture – AlloDerm that has been freeze-dried with no ice crystal formation
Right picture – Commercially available dermis after it has been freeze-dried by conventional methods. The lacy appearance is due to ice crystal damage to the extracellular matrix structure.
So, AlloDerm provides you with a bioactive matrix consisting of collagens, elastin, blood vessel channels and bioactive proteins that will support natural revascularization, cell repopulation and tissue remodeling. What more could you ask for?
Scar tissue is different from regenerated tissue. When an injury occurs, the body’s first reaction is homeostasis when fibrin and inflammatory cytokines form a blood clot or provisional scaffold. More inflammatory cells arrive, remodeling the clot into scar tissue. Collagen in scar tissue is abnormally aligned and has little elastin. Unlike regenerated tissue, scar tissue is different—and less perfect— than the surrounding tissue it replaces. Rather than triggering a scarring response, AlloDerm allows nature to follow its own regenerative process—restoring tissue to its original structural, functional, and physiological condition.
Blood vessel channels serve as conduits for revascularization. Collagens and elastin provide structure for cell repopulation. The preserved proteoglycans and proteins direct the patient’s won cell to initiate revascularization and cell repopulation.
There is significant revascularization in just over a week. AlloDerm is repopulated with cells and will begin remodeling into the patient’s own tissue over the next 3-6 months.
AlloDerm is naturally remodeled into the patient's own tissue.