surgical management of denuded root surfaces

1. DENUDED ROOT COVERAGE

2. Introduction

3. ETIOLOGY
Abnormal frenal and muscle attachment
Orthodontic tooth movement through a thin buccal
osseous plate
Direct gingival trauma from occlusion(eg :deep bite)
Gingival quality and quantityGingival quality and quantity
Iatrogenic factorsIatrogenic factors
Hard tooth brushingHard tooth brushing
Traumatic tooth brushingTraumatic tooth brushing
Tooth malpostionTooth malpostion

4. HALL(1977)-CRITICAL FACTORS:
1.Patients age
2.Patients dental needs
3.Level of oral hygiene
4.Teeth involved
5.Existing esthetics problem
6.Existing recession with
sensitivity problem

5. CLASSIFICATION
MILLER (1985)MILLER (1985)
Class I – Recession not extending to the muco-gingivalClass I – Recession not extending to the muco-gingival
junction. No loss of interdental bone or soft tissue.junction. No loss of interdental bone or soft tissue.
Class II –Recession extending to or beyond theClass II –Recession extending to or beyond the
mucogingival junction. No loss of interdental bone ormucogingival junction. No loss of interdental bone or
soft tissue.soft tissue.
Class III –Recession extending to or beyond theClass III –Recession extending to or beyond the
mucogingival junction. Loss of interdental bone or softmucogingival junction. Loss of interdental bone or soft
tissue is apical to cemento enamel junction but coronaltissue is apical to cemento enamel junction but coronal
to extent of marginal soft tissue recession.to extent of marginal soft tissue recession.
Class IV – Recession extending to or beyondClass IV – Recession extending to or beyond
mucogingival junction. Loss of interdental bone extendsmucogingival junction. Loss of interdental bone extends
to a level apical to extent of marginal soft tissueto a level apical to extent of marginal soft tissue

6. CLASSIFICATION
Sullivan and atkins (1968)
Shallow narrow
Shallow wide
Deep narrow
Deep wide

8. LATERALLY POSITIONED FLAP
The LPF was introduced by Grupe and Warren
in 1956. This was the first predictable method for
covering the avascular root surfaces by
maintaining its vascular connections through the
base and the body of transposed tissue.9

9. The success for LPF is dependent clinically on the
recognition and utilization of several
biologically based principles. These include:

10. INDICATIONS
Single sites
Narrow recessions
Mandibular central and lateral incisor defects
only

11. CONTRAINDICATIONS
Multiple contiguous sites
Inadequate tissue thickness on adjacent teeth
Inadequate keratinized tissue on adjacent teeth
Loss of interdental soft tissue or bone

12. ADVANTAGES
1. Good tissue blend
2. Usually one surgical site
3. Usually complete root coverage
DISADVANTAGE
1. Only one surgical site can be considered i.e. no
contiguous sites
2. Possible recession at the donor site

14. FREE GINGIVAL AUTOGRAFTS
Free gingival autografts are used to create a
widened zone of attached gingival. They were
initially described by Bjorn in 1963 and have
been extensively investigated since that time.

15. INDICATIONS
1. Inadequate zone of keratinized tissue.
2. Restorative concerns.
3. Shallow buccal vestibule.
4. Progressive active recession.
5. Multiple area of recession.
6. Anterior and posterior sextant defects of maxilla and
mandible.
CONTRAINDICATIONS
1. Need for esthetic root coverage.
2. Anatomic limitations (external oblique ridge).
3. Mandibular lingual recession.
4. Heavy smokers.

17. CORONALLY DISPLACED FLAP
The purpose of the coronally displaced flap
operation is to create a split thickness flap in the
area apical to the denuded root and displace it
coronally to cover the root.

18. INDICATIONS
1. Gingival recession with minimal labial sulcus
depth present
2. Adequate band of existing keratinized tissue
3. Maxillary arch usually restricted to the anterior
sextant

19. CONTRA INDICATIONS
1. Mandibular defects
2. Lack of keratinized gingiva
Two techniques are available for this purpose.

20. SEMILUNAR CORONALLY REPOSTIIONED
FLAP
The coronally positioned flap has been in
periodontics for many years with seve4al
different variations.
A technique originally described in the early
part of this century was presented recently
by Tarnow (1986) under the term “semi lunar
coronally repositioned flap”.

21. ADVANTAGE
Semilunar coronally repositioned flap
1. There is no tension on the flap after coronally
repositioning it.
2. There is no shortening of the vestibule.
3. The papillae mesial and distal to the tooth being
treated remain cosmetically unchanged.
4. No sutures are needed because of the lack of tension
of the tissue being coronally positioned.
DISADVANTAGES
1. Must have keratinized tissue.
2. Limited to the maxially arch.

22. SUB-EPITHELIAL CONNECTIVE TISSUE GRAFT
This technique uses a connective tissue graft
to cover denuded roots. It was described in
1985 by Langer and Langer, although similar
approaches had been previously reported by
Perez-Fernandez and Raetzke.

23. INDICATIONS
1. Inadequate donor site for a horizontal sliding flap.
2. Isolated wide gingival recession.
3. Multiple root exposures.
4. Multiple root exposures in combination with minimal
attached gingiva.
Recession adjacent to an edentulous area that also
requires ridge augmentation

24. ADVANTAGES
1. Covers the receded root with fibrotic tissue and
shows closer color blend of the graft with
adjacent tissue.
2. Donor site heals by primary intention with” less
discomfort than after a free gingival graft.

26. GUIDED TISSUE REGENERATION (GTR)
Since many periodontal surgeons have been
approaching certain problems with procedures aimed at
greater, more predictable regeneration of periodontal
tissue and functional attachment, beyond the use of
bone grafts and synthetic bone substitutes, treatment
approaches grouped under the term GTR have been
developed, analyzed and employed in clinical practice.
Thus GTR for exposed root coverage of human gingival
recession sites was introduced by Tiniti et al in 1992.

27. INDICATIONS
1. Narrow two-wall or three-wall intra bony defects with
atleast 4 mm of attachment loss and 4 mm intrabony
component.
2. Circumferential defects.
3. Class III furcation defects accompanied by a medium-
to-long root trunk.
4. Augmentation of ridge deficiencies.
5. Coverage of root recession.
6. Repair of apicoectomy defects.
7. Osseous fill around immediate implants placement
sites.
Repair of osseous defects associated with failing
implants.

28. CONTRAINDICATIONS
1. Poor oral hygiene.
2. Generalized horizontal bone loss.
3. Class III furcation defects.
4. Advanced defects with a minimal amount of remaining
periodontium.
5. Multiple adjacent defects.
6. Areas with an inadequate zone of attached gingival.
7. Class II furcations on the mesial and distal of
maxillary molars.
8. Premolar furcations.
9. One-walled intrabony defects.

29. The recent mode of treatment of denuded roots is
by using platelet concentrate get in a collagen
sponge carrier combined with a coronally
positioned flap.
RECENT ADVANCEMENTS

30. 1. 1. Fugi VII – pink glass inomer cement
2. 2. Gum veneers
The non surgical techniques include

31. GUM VENEERS
Provides lip support
restores symmetrical gingival architecture
replaces lost interdental papillae

32. TYPES
Acrylic resin gingival veneer
Flexible silicon gingival mask

33. INDICATIONS
In correction of gingival deformities
Root coverage after inflammation has been
controlled
Temporary splint
As interim measure in cases where final
treatment planning decisions are delayed

34. CONTRAINDICATIONS
PATIENTS WITH
 Poor plaque control
 Unstable periodontal health
 High caries activity
 Heavy smoking

35. ADVANTAGES
Painless procedure
Relatively inexpensive
Easily maintained by patients

36. DISADVANTAGES
Silicon gingival masks cannot be used in
patients with known allergy to silicon
Acrylic veneers are hard and rigid hence has
difficulties in fitting accurately around the teeth

37. CONCLUSION

38. Thank you