DEPARTMENT OFPERIODONTOLOGY AND IMPLANTOLOGY ROOT COVERAGE PROCEDURES Santosh Palla, CRRI Introduction… The term ,Mugogingival surgery (MGS) was coined by Friedman, for surgical alterations in relation to gingival oral mucosa BUT now Periodontic-plastic surgery( Miller 1993) is acceptable replacement for the MGS which broadly includes … 1. Perio-prostho Corrections 2. Crown lengthening 3. Root coverage procedures 4. Papilla reconstruction 5. Esthetic surgery for implants 6. Exposure of unerrupted teeth for Orthodontics REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,11 th editions” Sensitivity symptoms Ref :Kassab MM.Esthetics 3.What / Why root coverage?? 1. J Am Dent Assoc 2003.134:220-5. Gingival recession “Gingival recession is defined as exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction’* 2. Cohen RE. . The etiology and prevalence of gingival recession. 18:444-53. A classification of marginal tissue recession. . Int J Periodontics Restorative Dent 1985.The Disease… Understanding Gingival recession and its staging is a must before peeping into its Surgical correction… Lets me remind you PD Miller’s Classification REF: Miller Jr PD. Most of the Root coverage is implemented for I. JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 .Root Correction procedures Its fact that class III and IV recession cases have poor prognosis. REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD.II sometimes III classes. Step4: strips of gingiva placed at recipient site and sutured .Free Soft tissue grafts Free gingival auto graft Miller’s classical method Step1: root planning Step2: prepare recipient site Step3: obtain strips of free gingival graft. Levine.1991 Here the donor tissue is a connective tissue. otherwise procedure is similar to free gingival auto graft technique. It could be submerged( under a flap and sutured) or non submerged REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD. JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 .Free Soft tissue grafts Free connective tissue auto graft. Step1 prepare recipient site Step2 partial thickness flap is raised Step3 transfer flap laterally to cover root surface Step4 protect flap and donaor site.Warren 1956. Courtesy: Decision Making in Aesthetics: Root coverage Revisited PHILIPPE BOUCHARD. Used for isolated areas of denuded root having adequate donor tissue laterally. JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 STEPS REF: TEXTBOOK OF PERIODONTOLOGY F.th edin .Carranza 10.Pedicle soft tissue grafts Laterally dispalced flap: Grupe. JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 . Sliding partial thickness grafts from adjacent edentulous area under flap 4.Pedicle soft tissue grafts Laterally dispalced flap: Variations: 1. Preserving marginal attachment at donor site 3. Use of two flaps simultaneously REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD. Converging oblique incisions from recipient to donor site 2. Step2 scaling . Internal bevel incision to remove pocket wall. Elevate flap. .Pedicle soft tissue grafts Coronally dispalced flap: Making a split thickness flap apical to denunded root and its coronal placement is the principle of these flaps Step1 two vertical incisions.root planning Step3 return the falp and suture coronally VARIATION: submerging a free gingival autograft under flap. BHU. . TP Chaturvedi. Step 2: make a split thickness incision coronally and connect it to intrasulcular incision Step3 : Coronally falling tissue is repostioned 10 min and left as such.Pedicle soft tissue graftsBridge flap method Coronally dispalced flap: (Semilunar incison method) Tarnow technique. IMS..Pushpendra Kumar Verma1. Ruchi Srivastava2. IMAGE REF: Care report: Use of Coronally placed flaps in Root coverage with bridge flap method. Step1: semilunar incision made to end 2-3 mm above papilla of denuded root. th edin .Carranza 10. Root palnning 3. Obtain graft 4. Cover graft with outer part of flap and suture interdentally 6. Care of donor site and dressing at surgical site REF: TEXTBOOK OF PERIODONTOLOGY F. Steps: 1. proposed a variant subpediclle connective tissue flap to improve blood circulation quality. Indicated when large defects with good vestibular health and gingival thickness is seen.Sub-epithelial connective tissue graft Langer & langer 1985 introduced this method. Palcement in recipient site and suture with resorbalbe material 5. Nelson 1987. Here the donor tissue is sandwiched between flaps. elevate partial thickness flap carefully 2. Subepithelal Connective tissue graft . GTR membrane placement and adapted 3. Flap repositioned coronally + dressing 5. REF: TEXTBOOK OF PERIODONTOLOGY F.th edin . Suturing done with membrane 4.Carranza 10. Full thickness MP flap raised 2. weeks later GTR membrane removed by small envolope flap.GTR membranes Pini-Parto et al. Second surgery is not required in case of bio-resorbable material Steps: 1.:Guided tissue regeneration GTR membranes used for large defect’s root coverage Tinti-vencenzi proposed titanium membranes to create additional space beneath flap. GTR membrane . DMD Maurice.Salama.DMD Henry salama.DMD 10-7-2008 .Pouch and tunnel technique It is technique that will aid in intimate contact of recipient to donor site Post surgical aesthetics are superior after this method so indication for maxillary anterors IMAGE REF: Review of Tunnel technique in perodontic plastic surgery Dr David Garber. Tunnel technique Steps: 5..Pouch. Using sutures and curettes connective tissue is place in pouch and tunneled while covering defective of root. 6. 1. 2. Sulcular incision with #15c blade around recession Tunnel is made beneath adjacent buccal papilla A split thickness pouch is made apical to papilla above 12mm defect Pouch size(= defect area) measured and equal donor tissue borrowed 7. 4.Mesial and distal sites of donor are sutured with catgut and gingival flap is palced and horizontal matress sutures uesd. . 3. Holding sutures can be given if required along with periodontal dressing. JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 .Contents… IMAGE REF: Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD. Root surface modification agents Additive treatments AIM: to order to improve the biological link between the root surface and the covering soft tissues. Clinical evaluation of tetracycline HCl conditioning in the treatment of recessions. Nilve´us R. J Periodontol 1997 68: 262–269 .. Etienne D. Enamel matrix proteins Use for time lag of 2 min with a 24% EDTA containing enamel (Enamel matrix proteins gel) P gel onto root surfaces REF *:Bouchard P. • citric acid and tetracycline hydrochloride* It has been recommended to treat the roots with pH 1 citric acid for 3 min or with tetracycline (50–125 mg/ml for 3–5 min). Prognosis…?? Prediction of outcome of root coverage procedures is based on miller’s class defect treated ClassI . Complete root coverage may be achieved Class III Complete root coverage never achived . JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 . Complete root coverage achieved class II. Class IV Any root coverage not pridicted REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD. ... sensitivity how ever is the next. evaluation of gingival and periodontal status and requirements as per degree of defect must be understood prior to choosing one amongst the various Root Coverage procedures… AESTHETICS are prime concern in modern world.Conclusion… Patients general health. Etienne D. TP Chaturvedi.Salama. AND NOT BUT NOT THE LEAST WWW.. . 1. 4 Care report: Use of Coronally placed flaps in Root coverage with bridge flap method. The etiology and prevalence of gingival recession. *:Bouchard P.Pushpendra Kumar Verma1.BHU.. Ruchi Srivastava2.. JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 4.11 th editions 2 Ref :Kassab MM. IMS.Carranza 10.com.BHU IMAGES:. Nilve´us R. Etienne D. J Periodontol 1997 68: 262–269 3 . Pushpendra Kumar Verma1. REF: Miller Jr PD.DMD 10-7-2008 6..J Am Dent Assoc 2003. Clinical evaluation of tetracycline HCl conditioning in the treatment of recessions.DMD Henry salama. TP Chaturvedi.. • • • • • • • • • • • • • • INFORMATION : 1.DMD Maurice.134:220-5 3.DMD 10-7-2008 2. A classification of marginal tissue recession.. Int J Periodontics Restorative Dent 1985.Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD. 5.Google.. Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD.I Saw all these things….DMD Henry salama.DMD Maurice.Salama. Clinical evaluation of tetracycline HCl conditioning in the treatment of recessions. Cohen RE. Ruchi Srivastava2. Review of Tunnel technique in perodontic plastic surgery Dr David Garber..18:444-53. :Bouchard P. IMS. Review of Tunnel technique in perodontic plastic surgery Dr David Garber. TEXTBOOK OF PERIODONTOLOGY Femin A . JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000 IMAGE REF: Care report: Use of Coronally placed flaps in Root coverage with bridge flap method. J Periodontol 1997 68: 262–269 7. Nilve´us R.